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, 1 (1), 21-31

Modern Medical and Surgical Management of Difficult-To-Treat GORD

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Modern Medical and Surgical Management of Difficult-To-Treat GORD

Frank Zerbib et al. United European Gastroenterol J.

Abstract

Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when no oesophageal mucosal breaks are present at endoscopy and when extra-oesophageal symptoms are concerned. After failure of optimization of medical therapy, a careful work up is mandatory that aims at determining whether symptoms are related to GOR or not. Most patients with refractory symptoms do not have GOR-related symptoms. Some may have symptoms related to weakly acidic reflux and/or oesophageal hypersensitivity. Baclofen is currently the only antireflux compound available as add-on therapy to PPIs, but its poor tolerability limits its use in clinical practice. There is room for pain modulators in patients with hypersensitive oesophagus and functional heartburn. Antireflux surgery is a suitable option in patients responding to medical therapy who want to avoid taking medication or if persisting symptoms can be clearly attributed to poorly controlled GOR.

Keywords: Asthma; GORD; PPI; cough; surgery.

Figures

Figure 1.
Figure 1.
Algorithm of management for patients with typical refractory symptoms. aGORD is demonstrated by history of oesophagitis and/or positive pH monitoring off therapy. bpH-impedance monitoring is considered to be ‘positive’ when both SI and SAP are positive, and ‘negative’ when both SI and SAP are negative; non-concordant SI and SAP should be interpreted with caution before proposing antireflux surgery (adapted from Sifrim and Zerbib). cMay refer to positive symptom association to acid and/or non-acid reflux if pH-impedance monitoring is performed. NERD, non-erosive reflux disease; PPI, proton pump inhibitor; SAP, symptom association probability; SI, symptom index; SSRI, selective serotonin reuptake inhibitor; TLOSR, transient lower oesophageal relaxation.
Figure 2.
Figure 2.
Algorithm of management for patients with cough and/or ear, nose, and throat (ENT) symptoms according the presence (a) or not (b) of typical GORD symptoms. Regarding the potential role of weakly acidic reflux in this situation, patients with unexplained chronic cough may have pH-impedance monitoring off therapy instead of pH-alone reflux monitoring. PPI, proton pump inhibitor.
Figure 3.
Figure 3.
Algorithm of management for patients with difficult-to-treat asthma according to presence of GORD symptoms. pH-imp, pH-impedance monitoring; PPI, proton pump inhibitor.

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