Management of Refractory Gastroesophageal Reflux Disease with Atypical Gastrointestinal Symptoms

Diagnostic Evaluation

• The American Gastroenterological Association recommends that patients with refractory symptoms undergo prolonged esophageal pH monitoring (96 hours preferably) off proton pump inhibitor (PPI) therapy to confirm or rule out pathological gastroesophageal reflux disease (GERD) 1, 2, 3
• The European Society of Gastrointestinal Endoscopy suggests that endoscopy should be performed to rule out other causes of symptoms, such as esophagitis or Barrett's esophagus, and to assess for duodenal inflammation 1, 2
• The American College of Gastroenterology recommends that patients with refractory symptoms undergo testing for small intestine bacterial overgrowth (SIBO) and malabsorption, such as hydrogen/methane breath testing and fecal elastase testing 3, 1

Management of Refractory Symptoms

• The American Gastroenterological Association recommends that patients with refractory symptoms be evaluated for alternative causes of symptoms, such as SIBO, malabsorption, and celiac disease 1, 3
• The European Society of Gastrointestinal Endoscopy suggests that patients with refractory symptoms be considered for neuromodulator therapy, such as low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors, combined with cognitive-behavioral therapy, hypnotherapy, or diaphragmatic breathing techniques 5, 3

Algorithm-Based Decision Making

• If pH monitoring shows pathological GERD, the American College of Gastroenterology recommends that patients undergo 24-hour pH-impedance monitoring on PPI therapy to determine the mechanism of persistent symptoms (acid reflux vs. non-acid reflux vs. hypersensitivity to reflux) 1, 3
• If pH monitoring is normal, the American Gastroenterological Association recommends that patients be diagnosed with functional esophageal disorder (functional heartburn or hypersensitivity to reflux) and treated with neuromodulator therapy and cognitive-behavioral therapy 1, 5, 3

Common Errors to Avoid

• The American College of Gastroenterology recommends that empiric rotation of PPIs be avoided, as it has low yield and delays correct diagnosis 4, 1
• The European Society of Gastrointestinal Endoscopy suggests that assumption of GERD confirmation based on symptom improvement with PPI therapy be avoided, as it may be due to placebo effect or unrelated mechanisms 4
• The American Gastroenterological Association recommends that atypical gastrointestinal symptoms (such as yellowish malodorous stools) not be ignored, as they may require independent evaluation 4, 1