Refractory reflux disease. What kind of drug therapy and for how long? When to operate? [Therapieresistente Refluxkrankheit : Wie und Wie Lange Medikamentös Therapieren? Wann Operieren?]

Gastro-esophageal reflux disease (GERD) is common. Standard treatment includes lifestyle measures and proton pump inhibitors (PPIs). GERD is considered to be refractory to treatment when a standard dose of PPI fails to sufficiently control symptoms within 8 weeks. Severe reflux esophagitis may require a longer period of treatment. In the event of therapy-resistant GERD, a stratified approach is needed if diagnostic errors and therapeutic confusion are to be avoided. Major stumbling blocks are misdiagnosis, inadequate acid suppression, and a pathophysiological situation in which acid plays only a minor role. When other potential esophageal or extra-esophageal causes have been excluded, the first step is to optimise acid inhibition measures. If problems nevertheless persist, a functional diagnostic workup is indicated, preferably using a combination of pH-metry and impedance monitoring. Depending on the outcome, the therapeutic options that are then most likely to be useful are intensification and optimisation of the antisecretory treatment, measures aimed at relaxing the lower esophageal sphincter, modulation of esophageal sensitivity, and surgical reconstruction of the gastro-esophageal antireflux barrier. © 2009 Springer Medizin Verlag.