Update therapeutic approach to the upper GI diseases - focus on GERD

The first step in the management of upper gastrointestinal symptoms is to differentiate between organic and functional diseases.Endoscopy with advanced technologies and a series of invasive and non invasive function tests facilitate to make an accurate diagnosis and direct therapy. For gastric diseases (benign and malignant) the key demand is on adequate management of H. pylori gastritis and related complications. This will be the focus for another lecture (updated Maastricht V / Florence consensus report) during this congressual event. An emerging esophageal disease for its increasing incidence is the eosinophilic esophagitis and important development in management of this disease has taken place.
The major clinical challenge continues to be the adequate management of gastroesophageal reflux disease (GERD), and thus the focus of this presentation will be on GERD.
GERD is the top listed disease leading to a high frequency of medical consultations in outpatient settings of the Western world (1) and shows an increasing incidence in the Asian-Pacific world. The clinical spectrum of GERD embraces esophageal symptoms (heartburn, regurgitation) in the presence but as well in the absence of esophageal lesions (NERD/ERD). GERD presdisposes to preneoplastic lesions (Barrett esophagus) and to a variety of extraesophageal symptoms. It is more than 25 years, since PPI have been introduced in the clinical practice and they represent the mainstay in GERD therapy. However more recently PPI have been recognized for their therapeutic limitations in a variety of GERD related conditions (2).
PPI inadequate responsiveness of GERD-related symptoms is a big problem. The challenge is the correct diagnosis of GERD in patients presenting with normal esophageal mucosa by conventional white light endoscopy (non erosive GERD = NERD). The allocation of these patients to
a) "true" NERD, b) acid hypersensitive esophagus, c) non acid hypersensitive esophagus and d) functional heartburn is crucial.
New HD endoscopy and functional methods contribute to make a firm diagnosis.
Only with an accurate diagnosis of these conditions, targeted treatment strategies have a high probability of success (3).
For optimizing the therapy in GERD proper timing and dosing of PPI are essential. In case of PPI non - or partial responsiveness "add on" therapies are required and they include medications acting either on the mucosal resistance or by interfering with other reflux mechanisms (4-7). Several functional gastrointestinal disorders are overlapping with GERD and may require the addition of medications targeting dyspepsia and symptoms related to the irritable bowel syndrome (IBS). While the large majority of patients with GERD are best manageable with medications, selected cases may benefit from surgery (i.e. laparoscopic fundoplication). Recently several implantable devices have been developed and successfully tested for improvement of the antireflux barrier. At present they need to be critically viewed and wisely chosen for the management of the appropriate patient. Modern management of GERD is guided by high level evidence based studies, but for individual patient treatment we need to respect criteria of personalized medicine. A proposed algorithm for management is in tab. 1.

References
1) Peery AF, Crockett SD, Barritt AS et al. Burden of Gastrointestinal, Liver, and Pancreatic Diseases in the United States. Gastroenterology 2015;149,7:1731-1741
2) Boeckxstaens G, El-Serag HB, Smout AJ, Kahrilas PJ. Symptomatic reflux disease: the present, the past and the future. Gut 2014;63,7:1185-93
3) Sigterman KE, van Pinxteren B, Bonis PA et al. Short-term treatment with PPI, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2013;5:CD002095
4) Kahrilas PJ, McColl K, Fox M et al. The acid pocket: a target for treatment in reflux disease? Am J Gastroenterol 2013;108:1058-1064
5) Woodland P, Sifrim D. Oesophageal mucosal barrier: a key factor in the pathophysiology of non-erosive reflux disease (NERD) and a potential target for treatment. Gut 2014;63:705-706
6) Savarino E, Zentilin P, Savarino V. NERD: an umbrella term including heterogeneous subpopulations. Nature Rev Gastroenterol Hepatol 2013;10:371-380
7) Kandulski A, Malfertheiner P. Gastroesophageal reflux disease--from reflux episodes to mucosal inflammation. Nat Rev Gastroenterol Hepatol 2011;9,1:15-22