Review article. The classical approach to the gastroesophageal reflux disease (GERD) is focused on:

01 2 0 1 1 Gastroesophageal reflux disease refractory to proton pump inhibitors treatment M. Atanassova–Katelieva Gastroenterology clinic, UMHAT “St....
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Gastroesophageal reflux disease refractory to proton pump inhibitors treatment M. Atanassova–Katelieva Gastroenterology clinic, UMHAT “St.Marina”, Varna Keywords: GERD refractory to PPIs treatment Contact details: M. Atanassova, Gastroenterology clinic, UMHAT “St. Marina”, Varna, 1 Hristo Smirnenski Blvd., 2010 - Varna, Bulgaria, e-mail: [email protected]

Abstract: Gastroesophageal reflux disease (GERD) is one of the most common diseases in the gastroenterology practice. Approximately 10%-40% of the patients with GERD are refractory to proton pump inhibitors (PPIs) treatment. This problem is associated with the challenges it poses to the clinician: - determining of the ethiopathogenetic reasons for the poor therapeutic response – weakly acid reflux, bile reflux, residual acid reflux, eosinophilic esophagitis, esophageal hypersensitivity, etc.; - expansion of the diagnostic methods – fiber-optic esophago-gastro-duodeno-scopy (FEGDS) with biopsies of the esophageal mucosa, pH testing, impedance-pH testing; - treatment schemes with drugs from other groups; - assessment for anti-reflux surgery in some patients.

Review article The classical approach to the gastroesophageal reflux disease (GERD) is focused on: acid reflux, the most important pathogenetic component; acid suppression, as the main target of treatment; start of treatment, based rather on the symptoms (than on the pathogenesis); good symptomatic response to therapy with proton pump inhibitors (PPIs) confirming the role of acid reflux; poor response, which requires searching for other reasons. 30

Studies show that 10%-40% of patients with GERD have symptoms (regurgitation and heartburn) which are poorly or not affected by treatment with PPI6,13. The term GERD refractory to PPI treatment refers to absence or insufficient effect on the reflux symptoms upon intake of standard dose PPI for 4-8 weeks. The main groups of nonresponders to PPI treatment are patients with nonerosive GERD (NERD) or those with functional heartburn (FH), i.e. patients with normal pH in the esophagus and normal endoscopic findings.4 As a result of a four-week treatment with PPI once daily, 56% of the patients with reflux esophagitis (RE), 45% of those with FH, and only 37% of patients with NERD have symptomatic response.15 NERD patients who have low acid exposure in the esophagus (4.2%-9.9% of the total test time with pH 10% of the total test time with pH

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