Endotherapy for and tailored approaches to treating GERD, and refractory GERD

Abstract

This paper presents commentaries on how endoluminal antireflux procedures compare to laparoscopic fundoplication; new endoscopic procedures being studied to treat refractory gastroesophageal reflux disease (GERD); the new Stretta; the relationship between obesity and proton pump inhibitor (PPI) resistance; data concerning acid hypersensitivity and sensory receptors (vallinoid, TRPV1) causing refractory GERD; whether microscopic esophagitis is relevant in determining symptoms of non-erosive reflux disease (NERD); how concomitant functional gastrointestinal disorders affect the PPI response in NERD; the evidence that a functional esophagus is associated with inflammatory bowel syndrome (IBS); the role of GABA agonists in the treatment of refractory GERD; the role of biofeedback and antidepressants in refractory GERD; and endoluminal fundoplication using the EsophyX device.

Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions

“…Although biofeedback has been effective for a variety of medical conditions, evidence supporting its use for GERD symptoms is limited. 196 One prospective uncontrolled trial found that 7 of 12 patients with functional heartburn and functional chest pain refractory to acid suppression experienced symptom improvement for up to 9 months after using biofeedback to learn abdominal breathing exercises and muscle relaxation. 197 Two case reports have similarly demonstrated that biofeedback can be used to teach patients how to contract and relax their abdominal muscles, leading to improvement in pH score and LES pressure, and decreasing number of reflux events.…”

Narrative review of the role of inflammation in gastroesophageal reflux disease. Can food allergies play a part?

“…PPIs are routinely prescribed for both the treatment and differential diagnosis of GORD, and they are capable of improving overall injury scores in 90% of GORD patients and 65% of patients with laryngopharyngeal reflux 58 . Though their short‐term safety has been well established over the years, 2,59–60 there is increasing concern over their use as a long‐term treatment for GORD due to associated comorbidities 14–17 …”

“…Although both acid and nonacid components of refluxate have been demonstrated to be relevant in the symptom perception of GORD, 69,83,84 it is evident that they are by no means the only contributors to mucosal inflammation, with infection, obesity, immune dysfunction, comorbidities, dysbiosis, stress, and allergic responses also potentially being relevant 16,57,67,86 …”

“…To date, it is acknowledged that patients with refractory GORD may be considered to have functional heartburn or esophageal hypersensitivity in accordance with the Rome IV criteria 12 and also that weight gain and abdominal adiposity are key factors that can contribute to the perception of reflux severity and the response to PPIs 13 . Given the increasing concerns over the long‐term effects of PPI therapy, 14–18 it is important to explore the mechanisms that govern symptom perception in subgroups of the GORD population to determine whether inflammatory mechanisms which are not driven by acid exposure exist, thereby offering the potential for personalized treatment plans to be developed that provide greater efficacy and safety than acid‐suppression.…”

Endoluminal treatment for gastroesophageal reflux disease

“…These therapies are especially attractive to patients who respond well to acid suppression therapy, but have concerns about long term PPI use and the side effects of anti-reflux surgery (25). The evolution of endoscopic GERD treatment has focused on improving the function of the LES through the delivery of injectable agents or radiofrequency energy to the LES and on various endoscopic suturing devices to restore the structure and function of the incompetent LES (25)(26)(27).…”