Цель обзора – представить современные данные о причинах, методах диагностики и способах лечения рефрактерной формы гастроэзофагеальной рефлюксной болезни (ГЭРБ).
Рефрактерная ГЭРБ – это сохранение типичных симптомов заболевания и/или неполное заживление слизистой оболочки пищевода на фоне приема стандартной дозы ингибиторов протонной помпы (ИПП) 1 раз в день в течение 8 нед. Причины отсутствия ответа на проводимое лечения делятся на связанные с пациентом, связанные с терапией, а также не имеющие связи с ГЭРБ. Диагностические подходы включают в себя проведение рентгенологического исследования пищевода и желудка, эзофагогастродуоденоскопии с биопсией, 24-часовой рН-импедансометрии, манометрии пищевода. В зависимости от причин отсутствия ответа на проводимую терапию, лечение может включать изменение образа жизни, удвоение дозы ИПП, замену ИПП на другой, добавление Н2-блокаторов гистаминовых рецепторов, прокинетиков, антацидов, альгинатов и адсорбентов. При неэффективности консервативного лечения возможно рассмотрение вопроса об альтернативных методах, таких как хирургическое лечение.
Рефрактерное течение ГЭРБ представляет собой серьезную клиническую проблему. Отсутствие ответа на 8-недельную терапию ИПП требует проведения тщательной дифференциальной диагностики с применением дополнительных методов обследования. Выявление причин рефрактерности к проводимой терапии позволяет оптимизировать подходы к ее преодолению и выбирать оптимальную тактику лечения.
Purpose of the review to present up-to-date data on the causes, methods of diagnosis and treatment of the refractory form of gastroesophageal reflux disease (GERD).
Refractory GERD is the preservation of typical symptoms of the disease and/or incomplete healing of the esophageal mucosa against the background of taking a standard dose of proton pump inhibitors (PPI) once a day for 8 weeks. The reasons for the lack of response to the treatment are divided into related to the patient, related to therapy, and not related to GERD. Diagnostic approaches include x-ray examination of the esophagus and stomach, endoscopy with biopsy, 24-hour Impedance-pH monitoring, esophageal manometry. Depending on the reasons for the lack of response to the therapy, treatment may include lifestyle changes, doubling the dose of PPI, replacing PPI with another, adding H2-receptor antagonists, prokinetics, antacids, alginates and adsorbents. If conservative treatment is ineffective, it is possible to consider alternative methods, such as surgical treatment.
Refractory GERD is a serious clinical problem. The absence of an answer to 8-week therapy with PPI requires a thorough differential diagnosis using additional examination methods. The identification of the causes of refractory to the therapy allows to optimize the approaches to its overcoming and to choose the optimal treatment.
1. Ивашкин В.Т., Маев И.В., Трухманов А.С., Баранская Е.К., Дронова О.Б., Зайратьянц О.В., Сайфутдинов Р.Г., Шептулин А.А., Лапина Т.Л., Пирогов С.С., Кучерявый Ю.А., Сторонова О.А., Андреев Д.Н. Клинические рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению гастроэзофагеальной рефлюксной болезни. Российский журнал гастроэнтерологии, гепатологии, колопроктологии. 2017;27(4):75-95 [Ivashkin VT, Maev IV, Trukhmanov AS, Baranskaya EK, Dronova OB, Zayrat’yants OV, Sayfutdinov RG, Sheptulin AA, Lapina TL, Pirogov SS, Kucheryavyy YuA, Storonova OA, Andreev DN. Clinical recommendations of the Russian gastroenterological association for the diagnosis and treatment of gastroesophageal reflux disease. Rossiyskiy Zhurnal Gastroenterologii, Gepatologii, Koloproktologii. 2017;27(4):75-95 (In Russ.)].
doi: 10.22416/1382-4376-2017-27-4-75-95
2. Трухманов А.С. Диагностика и лечение гастроэзофагеальной рефлюксной болезни. Терапевтический архив. 2011;83(8):44-48 [Trukhmanov AS. Diagnosis and treatment of gastroesophageal reflux disease. Terapevticheskiy Arkhiv. 2011;83(8):44-48 (In Russ.)]
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5. Ивашкин В.Т., Маев И.В., Трухманов А.С. Пищевод Баррета. В 2-х т. Москва: Издательство «Шико»; 2011. С. 608-624 [Ivashkin VT,
Maev IV, Trukhmanov AS. Pishchevod Barreta [Barrett’s esophagus]. Moscow: Shiko; 2011. P. 608-624 (In Russ.)].
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7. Cicala M, Emerenziani S, Guarino MP, Ribolsi M. Proton pump inhibitor resistance, the real challenge in gastro-esophageal reflux disease. World J Gastroenterol. 2013;19(39):6529-6535.
8. Gunaratnam NT, Jessup TP, Inadomi J, Lascewski DP. Sub-optimal proton pump inhibitor dosing is prevalent in patients with poorly controlled gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2006;23:1473-14777.
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10. Fass R, Thomas S, Traxler B, Sostek M. Patient reported outcome of heartburn improvement: doubling the proton pump inhibitor (PPI) dose in patient who failed standard dose PPI vs. switching to a different PPI. Gastroenterology. 2004;146:A37.
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14. Сhang P, Friedenberg F. Obesity and GERD. Gastroenterol Clin. 2014;43:161-173.
15. Kouklakis G, Moschos J, Kountouras J. Relationship between obesity and gastroesophageal reflux disease as recorded by 3-hour esophageal pH monitoring. Rom J Gastroenterol. 2005;14(2):117-121.
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1. [Ivashkin VT, Maev IV, Trukhmanov AS, Baranskaya EK, Dronova OB, Zayrat’yants OV, Sayfutdinov RG, Sheptulin AA, Lapina TL, Pirogov SS, Kucheryavyy YuA, Storonova OA, Andreev DN. Clinical recommendations of the Russian gastroenterological association for the diagnosis and treatment of gastroesophageal reflux disease. Rossiyskiy Zhurnal Gastroenterologii, Gepatologii, Koloproktologii. 2017;27(4):75-95 (In Russ.)].
doi: 10.22416/1382-4376-2017-27-4-75-95
2. [Trukhmanov AS. Diagnosis and treatment of gastroesophageal reflux disease. Terapevticheskiy Arkhiv. 2011;83(8):44-48 (In Russ.)]
3. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, and the Global Consensus Group. The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus. Am J Gastroenterol. 2006;101:1900-1920.
4. El-Serag HB, Ergun GA, Pandolfino J, Fitzgerald S, Tran T, Kramer JR. Obesity increases oesophageal acid exposure. Gut. 2007;56:749-755.
5. [Ivashkin VT, Maev IV, Trukhmanov AS. Pishchevod Barreta [Barrett’s esophagus]. Moscow: Shiko; 2011. P. 608-624 (In Russ.)].
6. Bytzer P, van Zanten SV, Mattsson H, Wernersson B. Partial symptomresponse to proton pump inhibitors in patients with nonerosive reflux disease or reflux oesophagitis – a post hoc analysis of 5796 patients. Aliment Pharmacol Ther. 2012;36:635-643.
7. Cicala M, Emerenziani S, Guarino MP, Ribolsi M. Proton pump inhibitor resistance, the real challenge in gastro-esophageal reflux disease. World J Gastroenterol. 2013;19(39):6529-6535.
8. Gunaratnam NT, Jessup TP, Inadomi J, Lascewski DP. Sub-optimal proton pump inhibitor dosing is prevalent in patients with poorly controlled gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2006;23:1473-14777.
9. Johnson DA, Lauritsen K, Junghard O, Levine D. Evaluation of symptoms is an unreliable predictor of relapse of erosive esophagitis in patients receiving maintenance PPI therapy. Gastroenterology. 2003;124(4 Suppl 1):A540.
10. Fass R, Thomas S, Traxler B, Sostek M. Patient reported outcome of heartburn improvement: doubling the proton pump inhibitor (PPI) dose in patient who failed standard dose PPI vs. switching to a different PPI. Gastroenterology. 2004;146:A37.
11. Chey WD, Inadomi JM, Booher AM, Sharma VK, Fendrick AM, Howden CW. Primary-care physicians’ perceptions and practices on the management of GERD: results of a national survey. Am J Gastroenterol. 2005;100(6):1237-1242.
12. Yasuda S, Ohnishi A, Ogawa T, et al. Pharmacokinetic properties of E3810 a new proton pump ingibitor, in healthy male volunteers. Int J Clin Pharmacol Ther. 1994;32;466-473.
13. Boeckxstaens GE. Alterations confined to the gastro-oesophageal junction: the relationship between low LOSP, TLOSRs, hiatus hernia and acid pocket. Best Pract Res Clin Gastroenterol. 2010;24:821-829.
14. Сhang P, Friedenberg F. Obesity and GERD. Gastroenterol Clin. 2014;43:161-173.
15. Kouklakis G, Moschos J, Kountouras J. Relationship between obesity and gastroesophageal reflux disease as recorded by 3-hour esophageal pH monitoring. Rom J Gastroenterol. 2005;14(2):117-121.
16. El-Serag HB, Ergun GA, Pandolfino J, Fitzgerald S, Tran T, Kramer JR. Obesity increases oesophageal acid exposure. Gut. 2007;56:749-755.
17. Wu JC, Lai LH, Chow DK, Wong GL, Sung JJ, Chan FK. Concomitant irritable bowel syndrome is associated with failure of step-down on-demand proton pump inhibitor treatment in patients with gastro-esophageal reflux disease. Neurogastroenterol Motil. 2011;23(2):155-160.
18. Furuta T, Shirai N, Sugimoto M, Ohashi K, Ishizaki T. Pharmacogenomics of proton pump inhibitors. Pharmacogenomics. 2004;5(2):181-202.
19. Sim SC, Risinger C, Dahl ML, et al. A common novel CYP2C19 gene variant causes ultrarapid drug metabolism relevant for the drug response to proton pump inhibitors and antidepressants. Clin Pharmacol Ther. 2006;79(1):103-113.
20. Furuta T, Sugimoto M, Kodaira C, et al. CYP2C19 genotype is associated with symptomatic recurrence of GORD during maintenance therapy with low-dose lansoprazole. Eur J Clin Pharmacol. 2009;65:693-698.
21. Serrano D, Torrado S, Torrado-Santiago S, Gisbert JP. The influence of CYP2C19 Genetic polymorphism on the Pharmacokinetics/Pharmacodynamics of Proton Pump Inhibitor-Containing Helicobacter pylori treatment. Curr Drug Metab. 2012;13(9):1303-1312.
22. [Evsyuti-na YuV, Trukhmanov AS. A new look at the problem of gastroesophageal reflux disease, refractory to the treatment with proton pump inhibitors. Rossiyskiy Zhurnal Gastroenterologii, Gepatologii, Koloproktologii. 2014;(5):4-9 (In Russ.)].
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1 ФГАОУ ВО «Первый Московский государственный университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия;
2 ФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И. Евдокимова» Минздрава России, Москва, Россия
1 I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia;
2 A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia