Refractory gastroesophageal reflux disease: advances and treatment

Abstract

‘Refractory gastroesophageal reflux disease’ is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with ‘refractory symptoms.’ We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.

Keywords::

• achalasia
• acid suppressive therapy
• functional upper gut symptoms
• gastroparesis
• refractory symptoms

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Refractory gastroesophageal reflux disease (GERD) is one of the most common misnomers in the area of reflux disease.

• The role of reflux of gastroduodenal contents in many patients unresponsive to aggressive acid suppressive therapy remains less than conclusive.

• Many patients with refractory symptoms initially suspected reflux-related may suffers from gastroparesis, functional dyspepsia or other non-GERD conditions.

• Response to proton pump inhibitor therapy is an important clinical indicator of GERD and lack or partial response to such therapy must alert the health care provider to other potential etiologies.

• Nonacid reflux may be important if regurgitation is an important component of continued symptoms despite acid suppressive therapy.

• In patients unresponsive to acid suppressive therapy, GERD is most commonly not causal and a search for non-GERD causes must ensue.

Notes