Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.
Curr Opin Gastroenterol. 2013 Jul;29(4):431-6. doi: 10.1097/MOG.0b013e328360433c.
Treatment-refractory gastro-oesophageal reflux disease (GERD) remains a significant problem in the gastroenterology clinic. In recent years, several studies have investigated the assessment and treatment of refractory GERD.
Patients presenting with 'refractory GERD' in fact represent a quite heterogeneous group consisting of those with ongoing reflux-related symptoms and those with reflux-unrelated problems such as functional heartburn, dyspepsia or even eosinophilic oesophagitis. The greatest symptom indicators of persistent true reflux are retrosternal burning and acid taste in the mouth alone. Combined pH-impedance studies allow detection of reflux regardless of pH, and weakly acidic reflux has been suggested as a mechanism of residual symptoms in some patients. The use of reflux-symptom association calculations may help to determine the symptom causation, but refinement and outcome studies are needed. New treatments of refractory GERD have been disappointing. Surgery remains an option in very carefully selected patients, but again better outcome studies are required.
Careful history and investigation is required in the assessment of the proton pump inhibitor (PPI)-refractory patient. Care to exclude alternative diagnoses is needed, and to phenotype those with reflux-related symptoms. Optimization of PPI therapy may help, as may surgery in selected patients.
治疗抵抗性胃食管反流病（GERD）仍然是消化科的一个重大难题。近年来，多项研究调查了难治性 GERD 的评估和治疗方法。
实际上，表现为“治疗抵抗性 GERD”的患者是一个相当异质的群体，包括那些持续存在反流相关症状的患者和那些存在反流无关问题的患者，如功能性烧心、消化不良甚至嗜酸性食管炎。持续性真正反流的最大症状指标是胸骨后烧灼感和口中酸味。联合 pH 阻抗研究可以检测到无论 pH 值如何的反流，并且在一些患者中，弱酸性反流被认为是残留症状的一种机制。反流症状关联计算的使用可能有助于确定症状的病因，但需要进行细化和结局研究。难治性 GERD 的新治疗方法令人失望。手术仍然是在非常仔细选择的患者中的一种选择，但仍需要更好的结局研究。
质子泵抑制剂（PPI）抵抗性患者的评估需要仔细的病史和调查。需要排除其他诊断，并对有反流相关症状的患者进行表型分析。优化 PPI 治疗可能有帮助，在选择的患者中手术也可能有帮助。
