Dr Yadlapati provides guidance in the options for caring for patients who present with GERD that does not respond adequately to treatment.

Rena Yadlapati, MD, is director of the Center for Esophageal Diseases and professor of clinical medicine at the University of California San Diego.

TRANSCRIPT:

Hello, I'm Dr. Rena Yadlapati, professor of medicine at UC San Diego, where I direct the Esophageal Center, and I'm delighted to be here at ACG 2023. I gave a lecture today at the Past President's Symposium, and it was titled, How to Evaluate and Manage the Difficult Reflux Patient. Reflux is so common. About 30% of patients we see in clinic come in for these symptoms, and often they don't respond to proton pump inhibitors. And I think we really need to be thoughtful about why they're experiencing their symptoms. So top 3 reasons: They don't actually have GERD, so we need to do our due diligence and do the testing to make sure that they actually have GERD.

But let's say that they do have GERD. Well, it may be that it's not all about the acid, because proton pump inhibitor therapy is excellent at suppressing gastric acid. Now, there are some other acid blocking agents like H2 blockers or potassium competitive acid blockers, which are going to be approved in the near future for erosive esophagitis. But maybe it's because they have increased reflux episodes from intragastric pressure, common things being weight around the belly, wearing tight-fitting clothing around the belly, or a lot of abdominal strain. So being sure to talk to patients about that.

If they have a hiatal hernia, they're probably going to have a degree of mechanical reflux that proton pump inhibitors won't target, but they can modify their nighttime routines. Sleep on the left side. There's this new vibrating device that patients can wear, and it alerts them when they're not sleeping on the left side. Elevating the head of the bed is excellent. Medications like alginates, diaphragmatic breathing, all of these things are simple measures that patients can take. And then of course, we're fortunate to have surgical and endoscopic options. So fundoplication, magnetic sphincter augmentation or endoscopic fundoplication, all excellent options at restoring that antireflux barrier. We just need to make sure that the right patient is selected for the right treatment option.

And then finally, some patients have an increased sensitivity to reflux. It may be because there's some mucosal permeability that's increased in the esophagus. Maybe the nerves are hypersensitive, or there may be anxiety and hypervigilance at play. So be thoughtful about that. There's mucosal protective agents that you can consider, low dose antidepressants, and even psychotherapy that can be very beneficial. So remember, there's a lot more than PPIs. Just make sure you have the right patient, they actually have GERD, and be thoughtful about their mechanism. Thank you.