The tapestry of reflux syndromes: translating new insight into clinical practice

Kahrilas, Peter J.; Savarino, Edoardo; Anastasiou, Foteini; Bredenoord, Albert J.; Corsetti, Maura; Lagergren, Jesper; Mendive, Juan Manuel; Nelson, Sophie C.; Roman, Sabine; Zerbib, Frank; Hungin, Pali

doi:10.3399/bjgp21x717329

Cited by 12 publications

(6 citation statements)

References 28 publications

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“…A key contributor to PPI overutilization, especially high-dose and long-term use, is prescription for reflux-like symptoms (e.g., heartburn, regurgitation) or non-specific symptoms, leading to a presumptive diagnosis of “refractory” GORD. Despite growing awareness of “Disorders of Gut-Brain Interaction” and recognition of altered perception as a major determinant of reflux-like symptoms (reflux hypersensitivity and functional heartburn), PPIs remain a pragmatic first-line approach for patients presenting with reflux-like symptoms [ 27 ]. Dyspepsia and GORD clinical guidelines recommend 4–8 weeks of PPI treatment for resolution of GORD symptoms, after which PPIs should be discontinued [ 28 , 29 ].…”

Section: Key Drivers Of Ppi Overutilizationmentioning

confidence: 99%

Proton Pump Inhibitors: Rational Use and Use-Reduction – The Windsor Workshop

Kahrilas,

Anastasiou,

Bredenoord

et al. 2024

Dig Dis

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Background: Despite deprescribing initiatives to curb overutilization of proton pump inhibitors (PPIs), achieving meaningful reductions in PPI use is proving a challenge. Summary: An international group of primary care doctors and gastroenterologists examined the literature surrounding PPI use and use-reduction to clarify: (i) what constitutes rational PPI prescribing; (ii) when and in whom PPI use-reduction should be attempted; and (iii) what strategies to use when attempting PPI use-reduction. Key Messages: Before starting a PPI for reflux-like symptoms, patients should be educated on potential causes and alternative approaches including dietary and lifestyle modification, weight loss, and relaxation strategies. When commencing a PPI, patients should understand the reason for treatment, planned duration, and review date. PPI use at hospital discharge should not be continued without a recognized indication for long-term treatment. Long-term PPI therapy should be reviewed at least annually. PPI use-reduction should be based on the lack of a rational indication for long-term PPI use, not concern for PPI-associated adverse events. PPI use-reduction strategies involving switching to on-demand PPI or dose tapering, with rescue therapy for rebound symptoms, are more likely to succeed than abrupt cessation.

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Section: Key Drivers Of Ppi Overutilizationmentioning

confidence: 99%

Proton Pump Inhibitors: Rational Use and Use-Reduction – The Windsor Workshop

Kahrilas,

Anastasiou,

Bredenoord

et al. 2024

Dig Dis

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“…29 Manifestations related to acid reflux are more common in older patients (more than 45 years of age), those with central obesity, hiatus hernia and known lifestyle and dietary risk factors, such as high-fat diet and irregular eating habits. 29 On the other hand, functional symptoms are more common in younger patients and women, and frequently co-present with symptoms suggestive of gut-brain interaction disorder (postprandial fullness, nausea, early satiation, epigastric burning, IBS), [31][32][33] somatisation (e.g. fibromyalgia, headache, back pain, chronic fatigue, dizziness), 8,34,35 and anxiety.…”

Section: Patient-clinician Communicationmentioning

confidence: 99%

“…A comprehensive clinical history will help determine whether the predominant cause of reflux‐like symptoms is likely to be altered perception or altered physiology, an essential distinction to optimise individualised management (Figure 3). 29 Manifestations related to acid reflux are more common in older patients (more than 45 years of age), those with central obesity, hiatus hernia and known lifestyle and dietary risk factors, such as high‐fat diet and irregular eating habits 29 . On the other hand, functional symptoms are more common in younger patients and women, 30,31 and frequently co‐present with symptoms suggestive of gut‐brain interaction disorder (postprandial fullness, nausea, early satiation, epigastric burning, IBS), 31–33 somatisation (e.g.…”

Section: Personalised Managementmentioning

confidence: 99%

Review article: rethinking the “ladder” approach to reflux‐like symptom management in the era of PPI “resistance” ‐ a multidisciplinary perspective

Hungin

Scarpignato

Keefer

et al. 2022

Aliment Pharmacol Ther

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Summary Background Despite widespread adoption of potent acid suppression treatment with proton pump inhibitors (PPI) for reflux‐like symptoms, persistent symptoms are commonly reported in primary care and community studies. Aims This multidisciplinary review critically evaluates how the management of reflux‐like symptoms could better reflect their multifactorial pathophysiology. Methods A panel of experts (from general practice, gastroenterology and gastropsychology) attended a series of workshops to review current management and propose a framework for the provision of more individualised care. Results It was agreed that the perceptual (as well as the physiological) causes of reflux‐like symptoms should be considered at the start of management, not as a last resort when all else has failed. A short course of PPI is a pragmatic approach to address reflux‐like symptoms, but equally important is counselling about the gut‐brain axis and provision of symptom‐specific behavioural interventions for those who show signs of somatisation, hypervigilance or co‐existing disorders of gut‐brain interaction. Other low‐harm interventions such as lifestyle and dietary advice, should also be better integrated into care at an early stage. Multidisciplinary care management programmes (including dietary, weight loss, exercise and behavioural intervention) should be developed to promote greater self‐management and take advantage of the general shift toward the use of remotely accessed health care resources. Conclusions Management of reflux‐like symptoms should be adapted to reflect the advances in knowledge about the multifactorial aetiology of these symptoms, addressing both acid‐related and behavioural components early in management. The time has come to treat the patient, not the “disease”.

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“…FH patients do not respond to PPI therapy and, therefore, they should be treated with medications that can reduce visceral hypersensitivity and improve co-existing psychological dysfunction [ 23 ▪ ].…”

Section: Functional Heartburn Differs From Nonerosive Reflux Disease/...mentioning

confidence: 99%

Recent insights on functional heartburn and reflux hypersensitivity

Savarino

Marabotto

Savarino

2022

Current Opinion in Gastroenterology

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Purpose of reviewRome IV experts have proposed that gastroesophageal reflux disease (GERD) should be diagnosed only in patients with abnormal esophageal acid exposure, and that reflux hypersensitivity (RH) and functional heartburn (FH) both should be considered functional conditions separate from GERD. Although past and recent evidence support that FH can be completely distinguished from GERD, the concept that RH is not GERD is highly questionable. This review attempts to provide current data on these issues.Recent findingsMany recent investigations have provided new data on the different pathophysiological features characterizing RH and FH. Major differences have emerged from analyses of impedance-pH monitoring studies using the novel impedance metrics of baseline impedance (an index of mucosal integrity) and the rate of postreflux swallow-induced peristaltic waves (a reflection of the integrity of esophageal chemical clearance).SummaryThe better ability to interpret impedance-pH tracings together with earlier data on the different prevalence of microscopic esophagitis in RH and FH patients, and recent studies documenting poor therapeutic efficacy of pain modulators and good results of antireflux surgery for RH support recategorization of RH within the GERD world. Further research is needed to correctly phenotype patients who have heartburn without mucosal breaks, and to guide their effective management.

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The tapestry of reflux syndromes: translating new insight into clinical practice

Cited by 12 publications

References 28 publications

Proton Pump Inhibitors: Rational Use and Use-Reduction – The Windsor Workshop

Proton Pump Inhibitors: Rational Use and Use-Reduction – The Windsor Workshop

Review article: rethinking the “ladder” approach to reflux‐like symptom management in the era of PPI “resistance” ‐ a multidisciplinary perspective

Recent insights on functional heartburn and reflux hypersensitivity

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