Proton Pump Inhibitor Failure: Why Does It Occur and How Can It Be Managed?

The Italian validation of the Montreal Global definition and classification of gastroesophageal reflux disease

“…Finally, patients with functional heartburn are characterized by normal esophageal acid exposure and negative symptom index for both acid and nonacid reflux. These patients can no longer be considered to be affected by GERD and should be treated with drugs other than acid-lowering agents because they are responsible for the majority of PPI failures in patients with NERD [38]. In summary, NERD patients represent a large group, including a variety of heterogeneous populations that are progressively being identified and a distinct group of individuals with functional heartburn, who must be excluded from GERD.…”

“…Barrett's esophagus and adenocarcinoma (statements [33][34][35][36][37][38][39][40][41] In Montreal, the term 'Barrett's esophagus' was deemed confusing and ambiguous because the spectrum of what is currently referred to as 'Barrett's esophagus' ranges from diagnosis based solely on the endoscopic findings of any extent to the requirement that intestinal-type esophageal columnar metaplasia be proven histologically before this diagnosis is made [92,93]. The Rome members also considered the term 'Barrett's esophagus' to be ambiguous, and the agreement on the statement 33 (Table 5) was even stronger than in Montreal; however, the participants felt the principal reason for equivocation related to the presence of intestinal metaplasia as an essential factor for diagnosing Barrett's esophagus.…”

Current treatment options for esophageal diseases

“…Refractoriness to PPIs can be nonreflux related or reflux related. The nonreflux‐related esophageal causes include severe dysmotility syndromes, delayed gastric emptying, rumination syndrome, functional dyspepsia, functional heartburn, eosinophilic esophagitis, pill esophagitis, and infectious esophagitis . The reflux‐related causes that should be considered are (1) persistent abnormal esophageal acid exposure due to a lack of compliance with PPI therapy, incorrect medication dose timing, insufficient duration of acid suppression (i.e., nocturnal acid breakthrough), pathological acid secretion (i.e., Zollinger–Ellison syndrome), and rapid PPI metabolism; and (2) esophageal hypersensitivity to physiological amounts of acid, weakly acidic, and/or gas reflux (hypersensitive esophagus).…”

“…However, the regular use of H2RAs is limited by rapid development of tachyphylaxis and, therefore, they should be administrated at bedtime and on an intermittent basis . Further, ineffective control of acid secretion may be related to PPI metabolism, which may be caused by different polymorphisms of CYP2C19 . After considering these options, there are two potential strategies: switching to another PPI or doubling the dose.…”

Should We Screen for <i>Helicobacter pylori</i> to Prevent Gastric Cancer?

“…Resistance to antibiotics but also to proton pump inhibitors [17] associated with the re-infection with H. pylori may make H. pylori screening useless. Some time ago the use of antibiotics for orthopedic conditions offered the hope that antibiotherapy could prevent gastric cancer [18] , but this report has been a simple illusion.…”