Review: Managing Patients With Refractory Heartburn
Gastroesophageal reflux disease (GERD) is a highly prevalent condition that affects nearly 20% of an urban population and can significantly impact both health care costs as well as a patient's quality of life.1 In GERD, the reflux of stomach contents causes symptoms such as heartburn, regurgitation, pain in the chest, belching, and water brash, and can lead to more serious complications as well.
Treatment options for GERD include lifestyle modifications, pharmacological therapy, endoscopic therapy, and surgery.1 Proton-pump inhibitors (PPIs), which inhibit the secretion of gastric acid, are the mainstay pharmacological treatment option for patients with GERD. Unfortunately, it has been found that 20-42% of patients fail PPI therapy partially or completely, which leads to the continuation of heartburn symptoms, the manifestation of new symptoms, or the relapse of previously healed erosive esophagitis.
Refractory heartburn, or the persistence of heartburn despite treatment with a double dose of PPI therapy over at least an 8–12 week period, is believed to be caused by several different mechanisms (Table 1).1 Because the treatment of refractory heartburn is based on the underlying mechanism of the disease, proper diagnosis of the cause is a key step in treating a patient.
Several diagnostic methods are available to assess patients with refractory heartburn.1 Once a patient meets the criteria for refractory heartburn, upper endoscopy should be used to rule out the possibility of anatomical abnormalities found in either the esophagus or the stomach. For patients with unrevealing endoscopic findings, reflux testing is the next appropriate step. For patients with no history of GERD and not taking PPI therapy, the 24-hour pH test should be used. On the other hand, the multichannel intraluminal impedance-pH test is appropriate for patients with a documented history of GERD or for those taking PPI therapy.
Once the underlying cause of a patient's refractory heartburn is determined, appropriate therapy can be initiated.1 Figure 1 details the algorithm for the treatment of refractory heartburn based on the possible underlying mechanisms of the disease. Additionally, each mechanism is discussed in further detail in the remaining portion of this review.