title: Management of refractory typical GERD symptoms.
abstract: The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).
authors.affiliation: Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.|Division Gastroenterology, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy.
authors.forename: Emidio
authors.initials: E
authors.lastname: Scarpellini
authors.affiliation: Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
authors.forename: Daphne
authors.initials: D
authors.lastname: Ang
authors.affiliation: Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
authors.forename: Ans
authors.initials: A
authors.lastname: Pauwels
authors.affiliation: Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
authors.forename: Adriano
authors.initials: A
authors.lastname: De Santis
authors.affiliation: Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
authors.forename: Tim
authors.initials: T
authors.lastname: Vanuytsel
authors.affiliation: Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
authors.forename: Jan
authors.initials: J
authors.lastname: Tack
mesh_terms: D000464:Alginates / Q000627:therapeutic use; D000465:Algorithms; D000863:Antacids / Q000627:therapeutic use; D001418:Baclofen / Q000031:analogs & derivatives / Q000627:therapeutic use; D002908:Chronic Disease; D004945:Esophagoscopy / Q000379:methods; D005764:Gastroesophageal Reflux / Q000188:drug therapy / Q000601:surgery*; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D005773:Gastroscopy / Q000379:methods; D006801:Humans; D007555:Isoxazoles / Q000627:therapeutic use; D009125:Muscle Relaxants, Central; D018377:Neurotransmitter Agents / Q000627:therapeutic use; D010721:Phosphinic Acids / Q000627:therapeutic use; D011437:Propylamines / Q000627:therapeutic use; D014230:Triazoles / Q000627:therapeutic use
chemical_list: C587779:AZD2066; D000464:Alginates; D000863:Antacids; D005765:Gastrointestinal Agents; D007555:Isoxazoles; D009125:Muscle Relaxants, Central; D018377:Neurotransmitter Agents; D010721:Phosphinic Acids; D011437:Propylamines; D014230:Triazoles; C545087:lesogaberan; D001418:Baclofen; C543531:arbaclofen placarbil