Skip to main content
Top
Published in: Current Treatment Options in Gastroenterology 1/2020

01-03-2020 | Esophagitis | Esophagus (P Iyer, Section Editor)

New Developments in the Diagnosis and Management of Gastroesophageal Reflux

Authors: Yan Jiang, MD, John O. Clarke, MD

Published in: Current Treatment Options in Gastroenterology | Issue 1/2020

Login to get access

Abstract

Purpose of review

To examine recent key developments in the pathophysiology, diagnosis, and treatment of gastroesophageal reflux disease (GERD).

Recent findings

Newer research has suggested cytokine-mediated inflammation may play a role in the physiology of GERD, implying that the underlying mechanism may not be entirely related to chemical damage due to acid. Aided by novel technologies, diagnostic testing is also moving toward elucidating individual mechanisms and better defining specific GERD phenotypes with the goal of providing directed therapy. This is especially important in current times given the increase in coverage of adverse events reportedly linked to long-term proton pump inhibitor use.

Summary

As patients are looking for potential alternatives, we highlight the key recent updates in pathophysiology and understanding of GERD and current medical and endoscopic/surgical options and explore the exciting treatments in the pipeline.
Literature
4.
go back to reference Schumock GT, Li EC, Suda KJ, Wiest MD, Stubbings J, Matusiak LM, et al. National trends in prescription drug expenditures and projections for 2016. Am J Health-Syst Pharm: AJHP: official journal of the American Society of Health-System Pharmacists. 2016;73(14):1058–75. https://doi.org/10.2146/ajhp160205.CrossRef Schumock GT, Li EC, Suda KJ, Wiest MD, Stubbings J, Matusiak LM, et al. National trends in prescription drug expenditures and projections for 2016. Am J Health-Syst Pharm: AJHP: official journal of the American Society of Health-System Pharmacists. 2016;73(14):1058–75. https://​doi.​org/​10.​2146/​ajhp160205.CrossRef
5.
go back to reference Vaezi MF, Yang YX, Howden CW. Complications of proton pump inhibitor therapy. Gastroenterology. 2017;153(1):35–48. https://doi.org/10.1053/j.gastro.2017.04.047A review of studies examing PPI related adverse effects that concludes there is inadequate evidence to establish causal relationships of many reported effects. Recommends continued use in those with proven indication for PPI but discourages dose escalation and chronic therapy for those unresponsive to initial empiric trial. CrossRefPubMed Vaezi MF, Yang YX, Howden CW. Complications of proton pump inhibitor therapy. Gastroenterology. 2017;153(1):35–48. https://​doi.​org/​10.​1053/​j.​gastro.​2017.​04.​047A review of studies examing PPI related adverse effects that concludes there is inadequate evidence to establish causal relationships of many reported effects. Recommends continued use in those with proven indication for PPI but discourages dose escalation and chronic therapy for those unresponsive to initial empiric trial. CrossRefPubMed
6.
go back to reference Dunbar KB, Agoston AT, Odze RD, Huo X, Pham TH, Cipher DJ, et al. Association of acute gastroesophageal reflux disease with esophageal histologic changes. Jama. 2016;315(19):2104–12. https://doi.org/10.1001/jama.2016.5657A study examining esophageal biopsies of those with reflux esophagitis which showed an increase in T lymphocytes, providing evidence to suggest that cytokine mediated inflammation plays a role in mucosal injury. CrossRefPubMedPubMedCentral Dunbar KB, Agoston AT, Odze RD, Huo X, Pham TH, Cipher DJ, et al. Association of acute gastroesophageal reflux disease with esophageal histologic changes. Jama. 2016;315(19):2104–12. https://​doi.​org/​10.​1001/​jama.​2016.​5657A study examining esophageal biopsies of those with reflux esophagitis which showed an increase in T lymphocytes, providing evidence to suggest that cytokine mediated inflammation plays a role in mucosal injury. CrossRefPubMedPubMedCentral
12.
go back to reference Hirano I, Pandolfino JE, Boeckxstaens GE. Functional lumen imaging probe for the management of esophageal disorders: expert review from the clinical practice updates committee of the AGA Institute. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2017;15(3):325–34. https://doi.org/10.1016/j.cgh.2016.10.022.CrossRef Hirano I, Pandolfino JE, Boeckxstaens GE. Functional lumen imaging probe for the management of esophageal disorders: expert review from the clinical practice updates committee of the AGA Institute. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2017;15(3):325–34. https://​doi.​org/​10.​1016/​j.​cgh.​2016.​10.​022.CrossRef
15.
go back to reference Bakalar N Heartburn drugs can lead to fatal heart or kidney disease. New York Times. 2019 . Bakalar N Heartburn drugs can lead to fatal heart or kidney disease. New York Times. 2019 .
17.
go back to reference Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout A, et al. Modern diagnosis of GERD: the Lyon consensus. Gut. 2018;67(7):1351–62. https://doi.org/10.1136/gutjnl-2017-314,722Consensus statement defining specific GERD populations. Highlights conclusive endoscopic criteria for GERD, pH testing indications on/off PPI, abnormal pH testing parameters and current role of high resolution manometry. CrossRefPubMedPubMedCentral Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout A, et al. Modern diagnosis of GERD: the Lyon consensus. Gut. 2018;67(7):1351–62. https://​doi.​org/​10.​1136/​gutjnl-2017-314,722Consensus statement defining specific GERD populations. Highlights conclusive endoscopic criteria for GERD, pH testing indications on/off PPI, abnormal pH testing parameters and current role of high resolution manometry. CrossRefPubMedPubMedCentral
19.
go back to reference Hirano I, Zhang Q, Pandolfino JE, Kahrilas PJ. Four-day Bravo pH capsule monitoring with and without proton pump inhibitor therapy. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2005;3(11):1083–8.CrossRef Hirano I, Zhang Q, Pandolfino JE, Kahrilas PJ. Four-day Bravo pH capsule monitoring with and without proton pump inhibitor therapy. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2005;3(11):1083–8.CrossRef
21.
go back to reference Patel RCS, Jacobs J, Kumar A, Richter J. 96-h esophageal pH monitoring: the tiebreaker for abnormal DeMeester score and symptom index. Gastroenterology. 2018;154(6):S-487-7. Patel RCS, Jacobs J, Kumar A, Richter J. 96-h esophageal pH monitoring: the tiebreaker for abnormal DeMeester score and symptom index. Gastroenterology. 2018;154(6):S-487-7.
23.
go back to reference Frazzoni M, de Bortoli N, Frazzoni L, Tolone S, Furnari M, Martinucci I et al. The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring. Neurogastroenterol Motil: the official journal of the European Gastrointestinal Motility Society. 2017;29(3). doi:https://doi.org/10.1111/nmo.12947.CrossRef Frazzoni M, de Bortoli N, Frazzoni L, Tolone S, Furnari M, Martinucci I et al. The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring. Neurogastroenterol Motil: the official journal of the European Gastrointestinal Motility Society. 2017;29(3). doi:https://​doi.​org/​10.​1111/​nmo.​12947.CrossRef
25.
go back to reference Saritas Yuksel E, Higginbotham T, Slaughter JC, Mabary J, Kavitt RT, Garrett CG, et al. Use of direct, endoscopic-guided measurements of mucosal impedance in diagnosis of gastroesophageal reflux disease. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2012;10(10):1110–6. https://doi.org/10.1016/j.cgh.2012.05.018.CrossRef Saritas Yuksel E, Higginbotham T, Slaughter JC, Mabary J, Kavitt RT, Garrett CG, et al. Use of direct, endoscopic-guided measurements of mucosal impedance in diagnosis of gastroesophageal reflux disease. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2012;10(10):1110–6. https://​doi.​org/​10.​1016/​j.​cgh.​2012.​05.​018.CrossRef
28.
go back to reference Tucker E, Sweis R, Anggiansah A, Wong T, Telakis E, Knowles K, et al. Measurement of esophago-gastric junction cross-sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease. Neurogastroenterol Motil: the official journal of the European Gastrointestinal Motility Society. 2013;25(11):904–10. https://doi.org/10.1111/nmo.12218.CrossRef Tucker E, Sweis R, Anggiansah A, Wong T, Telakis E, Knowles K, et al. Measurement of esophago-gastric junction cross-sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease. Neurogastroenterol Motil: the official journal of the European Gastrointestinal Motility Society. 2013;25(11):904–10. https://​doi.​org/​10.​1111/​nmo.​12218.CrossRef
30.
32.
35.
go back to reference Aggarwal N, Thota PN, Lopez R, Gabbard S. A randomized double-blind placebo-controlled crossover-style trial of buspirone in functional dysphagia and ineffective esophageal motility. Neurogastroenterol Motil: the official journal of the European Gastrointestinal Motility Society. 2018;30(2). doi:https://doi.org/10.1111/nmo.13213.CrossRef Aggarwal N, Thota PN, Lopez R, Gabbard S. A randomized double-blind placebo-controlled crossover-style trial of buspirone in functional dysphagia and ineffective esophageal motility. Neurogastroenterol Motil: the official journal of the European Gastrointestinal Motility Society. 2018;30(2). doi:https://​doi.​org/​10.​1111/​nmo.​13213.CrossRef
36.
go back to reference Thomas E, Wade A, Crawford G, Jenner B, Levinson N, Wilkinson J. Randomized clinical trial: relief of upper gastrointestinal symptoms by an acid pocket-targeting alginate-antacid (Gaviscon Double Action) - a double-blind, placebo-controlled, pilot study in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2014;39(6):595–602. https://doi.org/10.1111/apt.12640.CrossRefPubMed Thomas E, Wade A, Crawford G, Jenner B, Levinson N, Wilkinson J. Randomized clinical trial: relief of upper gastrointestinal symptoms by an acid pocket-targeting alginate-antacid (Gaviscon Double Action) - a double-blind, placebo-controlled, pilot study in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2014;39(6):595–602. https://​doi.​org/​10.​1111/​apt.​12640.CrossRefPubMed
37.
go back to reference Wilkinson JWA, Thomas SJ, Jenner B, Hodgkinson V, Coyle C. Randomized clinical trial: a double-blind, placebo-controlled study to assess the clinical efficacy and safety of alginate-antacid (Gaviscon Double Action) chewable tablets in patients with gastro-oesophageal reflux disease. Eur J Gastroenterol Hepatol. 2019;31(1):86–93.CrossRef Wilkinson JWA, Thomas SJ, Jenner B, Hodgkinson V, Coyle C. Randomized clinical trial: a double-blind, placebo-controlled study to assess the clinical efficacy and safety of alginate-antacid (Gaviscon Double Action) chewable tablets in patients with gastro-oesophageal reflux disease. Eur J Gastroenterol Hepatol. 2019;31(1):86–93.CrossRef
40.
go back to reference Vaezi MF, Fass R, Vakil N, Mittleman R, Hall M, Reasner DS, et al. 875 - Iw-3718, a novel gastric-retentive bile acid sequestrant, improved heartburn and regurgitation symptoms in patients with persistent gerd despite PPI treatment: a double-blind, placebo-controlled study. Gastroenterology. 2018;154(6):S-174. https://doi.org/10.1016/S0016-5085(18)30995-8.CrossRef Vaezi MF, Fass R, Vakil N, Mittleman R, Hall M, Reasner DS, et al. 875 - Iw-3718, a novel gastric-retentive bile acid sequestrant, improved heartburn and regurgitation symptoms in patients with persistent gerd despite PPI treatment: a double-blind, placebo-controlled study. Gastroenterology. 2018;154(6):S-174. https://​doi.​org/​10.​1016/​S0016-5085(18)30995-8.CrossRef
41.
go back to reference Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2015;13(6):1058–67.e1. https://doi.org/10.1016/j.cgh.2014.10.013.CrossRef Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2015;13(6):1058–67.e1. https://​doi.​org/​10.​1016/​j.​cgh.​2014.​10.​013.CrossRef
43.
go back to reference Ganz RA, Edmundowicz SA, Taiganides PA, Lipham JC, Smith CD, De Vault KR, et al. Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2016;14(5):671–7. https://doi.org/10.1016/j.cgh.2015.05.028Five year follow up of an initial multicenter trial of patients receiving MSA which showed a significant decrease in GERD-HRQL scores, moderate to severe regurgitation symptoms and PPI use (100% of patients initially to 15.3% of patients at follow up). CrossRef Ganz RA, Edmundowicz SA, Taiganides PA, Lipham JC, Smith CD, De Vault KR, et al. Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association. 2016;14(5):671–7. https://​doi.​org/​10.​1016/​j.​cgh.​2015.​05.​028Five year follow up of an initial multicenter trial of patients receiving MSA which showed a significant decrease in GERD-HRQL scores, moderate to severe regurgitation symptoms and PPI use (100% of patients initially to 15.3% of patients at follow up). CrossRef
47.
go back to reference Testoni PA, Testoni S, Mazzoleni G, Vailati C, Passaretti S. Long-term efficacy of transoral incisionless fundoplication with Esophyx (Tif 2.0) and factors affecting outcomes in GERD patients followed for up to 6 years: a prospective single-center study. Surg Endosc. 2015;29(9):2770–80. https://doi.org/10.1007/s00464-014-4008-6.CrossRefPubMed Testoni PA, Testoni S, Mazzoleni G, Vailati C, Passaretti S. Long-term efficacy of transoral incisionless fundoplication with Esophyx (Tif 2.0) and factors affecting outcomes in GERD patients followed for up to 6 years: a prospective single-center study. Surg Endosc. 2015;29(9):2770–80. https://​doi.​org/​10.​1007/​s00464-014-4008-6.CrossRefPubMed
50.
go back to reference Inoue H, Ito H, Ikeda H, Sato C, Sato H, Phalanusitthepha C, et al. Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study. Ann Gastroenterol. 2014;27(4):346–51.PubMedPubMedCentral Inoue H, Ito H, Ikeda H, Sato C, Sato H, Phalanusitthepha C, et al. Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study. Ann Gastroenterol. 2014;27(4):346–51.PubMedPubMedCentral
51.
go back to reference Inoue H, Sumi K, Tatsuta T, Ikebuchi Y, Tuason J. 998 clinical results of antireflux mucosectomy (ARMS) for refractory Gerd. Gastrointest Endosc. 2017;85(5):AB120. https://doi.org/10.1016/j.gie.2017.03.196Research describing experience and results of a novel technique currently used in Japan for refractory GERD. This 67 patient cohort study, expanding on an initial pilot study, shows significant decrease in reflux symptoms, endoscopic flap valve grade, percent time clearance pH, and PPI use 1 year post procedure.CrossRef Inoue H, Sumi K, Tatsuta T, Ikebuchi Y, Tuason J. 998 clinical results of antireflux mucosectomy (ARMS) for refractory Gerd. Gastrointest Endosc. 2017;85(5):AB120. https://​doi.​org/​10.​1016/​j.​gie.​2017.​03.​196Research describing experience and results of a novel technique currently used in Japan for refractory GERD. This 67 patient cohort study, expanding on an initial pilot study, shows significant decrease in reflux symptoms, endoscopic flap valve grade, percent time clearance pH, and PPI use 1 year post procedure.CrossRef
52.
go back to reference Kappelle WF, Bredenoord AJ, Conchillo JM, Ruurda JP, Bouvy ND, van Berge Henegouwen MI, et al. Electrical stimulation therapy of the lower oesophageal sphincter for refractory gastro-oesophageal reflux disease - interim results of an international multicentre trial. Aliment Pharmacol Ther. 2015;42(5):614–25. https://doi.org/10.1111/apt.13306.CrossRefPubMed Kappelle WF, Bredenoord AJ, Conchillo JM, Ruurda JP, Bouvy ND, van Berge Henegouwen MI, et al. Electrical stimulation therapy of the lower oesophageal sphincter for refractory gastro-oesophageal reflux disease - interim results of an international multicentre trial. Aliment Pharmacol Ther. 2015;42(5):614–25. https://​doi.​org/​10.​1111/​apt.​13306.CrossRefPubMed
Metadata
Title
New Developments in the Diagnosis and Management of Gastroesophageal Reflux
Authors
Yan Jiang, MD
John O. Clarke, MD
Publication date
01-03-2020
Publisher
Springer US
Published in
Current Treatment Options in Gastroenterology / Issue 1/2020
Print ISSN: 1092-8472
Electronic ISSN: 1534-309X
DOI
https://doi.org/10.1007/s11938-020-00275-1

Other articles of this Issue 1/2020

Current Treatment Options in Gastroenterology 1/2020 Go to the issue

Neurogastroenterology and GI Motiliy (H Parkman and R Schey, Section Editors)

Rumination Syndrome: Recognition and Treatment

Inflammatory Bowel Disease (G Lichtenstein, Section Editor)

Current Endpoints of Clinical Trials in Ulcerative Colitis: Are They Valid?