Zusammenfassung
Da die gastroösophageale Refluxerkrankung (GERD) eine Motilitätsstörung ist, ist die Therapie auch mit modernen Protonenpumpenhemmern (PPI) symptomatisch und führt nach Absetzen in über 90% der Fälle zum Rezidiv. Dieses „therapeutische Dilemma“ wird bei den klinischen Problemfällen deutlich (PPI-Therapierefraktärität, Notwendigkeit hoher PPI-Dosen, Volumenreflux), bei denen die alleinige Säureblockade nicht zu einem befriedigenden Behandlungseffekt führt. In dem Beitrag werden weitere Faktoren diskutiert, die neben dem Säurereflux eine Bedeutung bei GERD haben können. Hierzu zählen neben der Motilität und den verschiedenen Barrierefunktionen der Speiseröhre grundsätzliche Probleme in der Beurteilung eines Therapieerfolgs (Placeboeffekt, Spontanremission), die Rolle der Sensorik und der subjektiven Empfindung, der fließende Übergang zur Erkrankung bzw. von GERD zu funktionellen Beschwerden und der Einfluss des duodenogastroösophagealen Reflux bzw. der Helicobacter-pylori-Infektion.
Abstract
Because gastroesophageal reflux disease (GERD) is a motility disorder, acid reduction with proton pump inhibitors (PPI) remains a symptomatic therapy with a recurrence rate of over 90% after discontinuation of acid suppression. This “therapeutic dilemma” becomes obvious in patients not responding sufficiently to the conventional medication (therapy resistance, necessity of high PPI doses, volume reflux). In this manuscript we analyze additional factors that may play a role in the pathogenesis and interpretation of GERD. These additional factors include gastroesophageal motility and esophageal barrier functions as well as duodenogastroesophageal reflux and Helicobacter pylori infection. In addition, basic problems in interpretation of therapeutic success such as placebo effect, spontaneous remission of GERD, the role of sensory function and subjective interpretation of symptoms and the overlap between physiological and pathological reflux as well as functional disorders will be discussed.
Literatur
Dent J, Brun J, Frederick A et al. (1999) An evidence-based appraisal of reflux disease management—the Genval Workshop Report. Gut 44 [Suppl]: 2
McDougall NI, Johnston BT, Kee F et al. (1996) Natural history of reflux oesophagitis: a 10 year follow up of ist effect on patient symptomatology and quality of life. Gut 38: 481–486
Pace F, Santalucia F, Porro GB (1991) Natural history of gastro-oesophageal reflux disease without oesophagitis. Gut 32: 845–848
Aste H, Bonelli L, Ferraris R et al. (1999) Gastroesophageal reflux disease. Relationship between clinical and histological features. Dig Dis Sci 44: 2412–2418
Kuster E, Ros E, Toledo-Pimentel V et al. (1994) Predictive factors of the long-term outcome in gastro-oesophageal reflux disease: six-year follow-up of 107 patients. Gut 35: 8–14
Howard PJ, Heading RC (1992) Epidemiology of gastro-esophageal reflux disease. World J Surg 16: 288–293
Holtmann G (2001) Reflux disease. The disorder of the third millenium. Er J Gastroenterol Hepatol 13 [Suppl 1]: S5–S11
Stanghellini V (1999) Three-month prevalence rates of gastrointestinal symptoms and the influence of demographic factors: Results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol 231 [Suppl]: 20–28
Klauser AG, Schindlbeck NE, Müller-Lissner SA (1990) Symptoms in gastrooesophageal reflux disease. Lancet 335: 205–208
Hotz J, Madisch A, Classen M, Malfertheiner P, Rösch W (2000) Internationaler Konsens zur Refluxkrankheit der Speiseröhre. Dtsch Med Wochenschr 125: 1308–1312
Kusano M, Ino K, Yamada T, Kawamura O et al. (1999) Interobserver and intraobserver variation in endoscopic assessment of GERD using the „Los Angeles“ classification. Gastrointest Endosc 49: 600–704
Lundell LR, Dent J, Bennett JR et al. (1999) Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 45: 172–180
Öberg S, Peters JH, DeMeester TR, Lord RV, Johansson J, Crookes PF, Bremner CG (1999) Endoscopic grading of the gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD). Surg Endosc 13: 1184–1188
Fass R, Ofman JJ, Sampliner RE, Camargo L, Wendel C, Fennerty MB (2000) The omeprazole test is as sensitive as 24-h oesophageal pH monitoring in diagnosing gastro-oesophageal reflux disease in symptomatic patients with erosive oesophagitis. Aliment Pharmacol Ther 14: 389–396
Pehl C, Keller J (2004) 24-Stunden-Ösophagus-pH-Metrie. Empfehlungen des Arbeitskreises Neurogastroenterologie und Motilität.http://www.neurogastro.de
Karaus M, Allescher HD (2004) Manometrie von Ösophagus und Anorektum. Empfehlungen des Arbeitskreises Neurogastroenterologie und Motilität.http://www.neurogastro.de
Carlsson R, Dent J, Watts R et al. (1998) Gastro-oesophageal reflux disease in primary care: an international study of different treatment strategies with omeprazole. International GORD Study Group. Eur J Gastroenterol Hepatol 10: 119–124
Triadafilopoulos G, DiBaise JK, Nostrant TT et al. (2002) The Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the U.S. open label trial. Gastrointest Endosc 55: 149–156
DiBaise JK, Brand RE, Quigley EM (2002) Endoluminal delivery of radiofrequency energy to the gastroesophageal junction in uncomplicated GERD: efficacy and potential mechanism of action. Am J Gastroenterol 97: 833–842
Corley DA, Katz P, Wo JM et al. (2003) Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial. Gastroenterology 125: 668–676
Filipi CJ, Lehman GA, Rothstein RI et al. (2001) Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial. Gastrointest Endosc 53: 416–422
Mahmood Z, McMahon BP, Arfin Q, Byrne PJ, Reynolds JV, Murphy EM, Weir DG (2003) Endocinch therapy for gastro-oesophageal reflux disease: a one year prospective follow up. Gut 52: 34–39
Feretis C, Benakis P, Dimopoulos C et al. (2001) Endoscopic implantation of Plexiglas (PMMA) microspheres for the treatment of GERD. Gastrointest Endosc 53: 423–426
Deviere J, Pastorelli A, Louis H et al. (2002) Endoscopic implantation of a biopolymer in the lower esophageal sphincter for gastroesophageal reflux: a pilot study. Gastrointest Endosc 55: 335–341
Johnson DA, Ganz R, Aisenberg J et al. (2003) Endoscopic implantation of enteryx for treatment of GERD: 12-month results of a prospective, multicenter trial. Am J Gastroenterol 98: 1921–1930
Fockens P, Costamagna G, Gabriella A (2002) Endoscopic augmentation of the lower esophageal sphincter (LES) for the treatment of GERD: multicenter study of the gatekeeper reflux repair system. Gastrointest Endosc 55: AB 90
Arts J, Van Olmen A, D’Haens G et al. (2003) Radiofrequency delivery at the gastroesophageal junction in GERD improves acid exposure and symptoms and decreases esophageal sensitivity to acid. Gastroenterology 124: A148
Wenzel G, Heise J, Kuhlbusch R, Frieling T (2003) Die Symptombesserung nach endoskopischer Antirefluxtherapie ist durch eine verminderte Säure-Perzeption bedingt. Z Gastroenterol 41: 754
Müller-Lissner S (2001) Endoskopische plastische Chirurgie der Kardia. Z Gastroenterol 39: 819–822
Fass R, Tougas G. (2002) Functional heartburn: The stimulus, the pain and the brain. Gut 51: 885–892
Williams D, Thompson DG, Heggie L et al. (1994) Esophageal clearance function following treatment of esophagitis. Gastroenterology 106: 108–116
Singh P, Adamopoulos A, Taylor RH et al. (1992) Motorische Funktion des Ösophagus vor und nach Ausheilung einer Ösophagitis. Gut 33: 1590–1596
Eckardt VF (1988) Does healing of esophagitis improve esophageal motor function? Dig Dis Sci 33: 161–165
Orlando RC (1997) The pathogenesis of gastroesophageal reflux disease: the relationship between epithelial defense, dysmotility, and acid exposure. Am J Gastroenterol 92: 3S–5S
Marshall RE, Anggiansah A, Owen WA et al. (2001) The extent of duodenogastric reflux in gastro-oesophageal reflux disease. Eur J Gastroenterol Hepatol 13: 5–10
Marshall REK, Anggiansah A, Owen WA, Owen WJ (1997) The relationship between acid and bile reflux and symptoms in gastro-oesophageal reflux disease. Gut 40: 182–187
Nehra D, Howell P, Williams CP et al. (1999) Toxic bile acids in gastro-oesophageal reflux disease: influence of gastric acidity. Gut 44: 598–602
Penagini R (2001) Bile reflux and oesophagitis. Eur J Gastroenterol Hepatol 13: 1–3
Dent J (2001) Review article: is Helicobacter pylori relevant in the management of reflux disease ? Aliment Pharmacol Ther 15: 16–21
Sharma P (2001) Helicobacter pylori: a debated factor in gastroesophageal reflux disease. Dig Dis 19: 127–133
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Frieling, T. Antirefluxtherapie—mehr als Säureblockade?. Internist 45, 1364–1369 (2004). https://doi.org/10.1007/s00108-004-1291-7
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DOI: https://doi.org/10.1007/s00108-004-1291-7