| Rome IV introduced for the first time two separate functional esophageal disorders with heartburn as their predominant symptom. They include functional heartburn, which was previously recognized as a functional esophageal disorder, and reflux hypersensitivity, which was previously considered a subgroup of nonerosive reflux disease (NERD). Both functional esophageal disorders are the main underlying mechanism for persistent heartburn despite twice-daily PPI in up to 90% of the patients. Furthermore, Rome IV also introduced another new concept, which was not mentioned in the previous Rome criteria, that functional esophageal disorders, specifically functional heartburn and reflux hypersensitivity, may overlap with GERD. Rome IV emphasized that patients with documented GERD who failed PPI treatment likely have an overlap with a functional esophageal disorder. It is the latter that is responsible for patients’ symptoms. This concept is a breakthrough in our understanding of the mechanisms that lead to persistent symptoms in GERD patients who are on PPI treatment. It also ties together the previous reports about esophageal hypersensitivity and psychological comorbidity as potential underlying mechanisms for failure of PPI treatment in GERD patients. A recent study further helped to cement the overlap concept between GERD and functional esophageal disorders in PPI failure patients by demonstrating that 75% of the GERD patients who continued to have symptoms on once-daily PPI had an overlap with either functional heartburn (62.5%) or reflux hypersensitivity (12.5%). The authors concluded that most GERD patients who failed PPI treatment have an overlap with functional heartburn or reflux hypersensitivity, which are likely responsible for patients’ lack of response to treatment. Recognizing that most PPI failure in patients with documented GERD is the result of an overlap with a functional esophageal disorder may improve our current management of this common clinical dilemma. Treatment that focus on pain modulators, psychological intervention, or complimentary medicine techniques may be needed in addition to anti-reflux medications to provide full control of symptoms. Moreover, educating physicians from all disciplines, as well as patients, about the relationship between GERD and functional esophageal disorders may simplify the diagnostic process. |
