Gastroenterology

Gastroenterology

Volume 154, Issue 2, January 2018, Pages 302-318
Gastroenterology

Gastroesophageal Reflux Disease
Management of Gastroesophageal Reflux Disease

https://doi.org/10.1053/j.gastro.2017.07.049Get rights and content

Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.

Section snippets

Lifestyle

Lifestyle measures designed to reduce reflux symptoms are typically initiated at presentation, and should be recommended for all patients with GERD. Unfortunately, many physicians either do not provide clear instructions for lifestyle modifications or offer patients a printed list of activities and food items to avoid, which patients find hard to follow.11 Some patients report specific foods that induce GERD symptoms, including citrus, spicy food, caffeine, chocolate, and fatty foods. However,

Antireflux Surgery

After peaking in 2009, use of antireflux surgery (ARS) decreased to levels a decade ago (0.05% of patients with GERD), indicating reduced enthusiasm among referring physicians and patients alike.90 For the average patient, ARS is pursued in the following 3 settings: as an option for long-term management of GERD over medical therapy, for persistent proven GERD symptoms or esophageal mucosal damage despite maximal medical therapy, and when there is significant structural disruption at the EGJ

PPI Nonresponders

As many as 40% of patients with heartburn have either an incomplete or complete lack of response to once-daily PPIs.122 The proportion of patients with persistent troublesome heartburn despite once-daily PPI use was 32% in in randomized trials and 17% in nonrandomized trials, respectively; the proportion of patients with persistent regurgitation was 28% in randomized and nonrandomized trials.123 As many as 54% of patients with GERD might not take their PPIs optimally, which reduces efficacy.124

Future Directions

Drug development in GERD has considerably decreased over the past decade, primarily because most PPIs have become generic and are available over-the-counter.186 In contrast, there has been growing interest in nonmedical therapeutic strategies, especially for patients who are not interested in, allergic to, noncompliant with, or concerned about long-term PPI treatment.187

Potassium-competitive acid blockers (P-CABs) inhibit the proton pump in a K+ competitive but reversible mechanism. P-CABs

Conclusions

Current strategies for management of GERD are based on several decades of pharmaceutical and nonpharmacologic therapeutic development that have considered the risks, albeit limited, of chronic acid suppression. There is growing recognition that functional esophageal disorders (functional heartburn and reflux hypersensitivity) are the leading mechanisms for persistent heartburn. The basic tenets of GERD management today are as follows: management with a PPI only when necessary, at the lowest

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    Conflicts of interest R.F. is an advisor to Ironwood, Mederi Therapeutics and Ethicon. Speaker for AstraZeneca, Takeda and Mederi Therapeutics and receives a research grant from Ironwood. C.P.G is an advisor to Torax, Ironwood, Medtronic and Diversatek. Speaker for Medtronic and Diversatek.

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