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Therapieresistente Refluxkrankheit

Wie und wie lange medikamentös therapieren? Wann operieren?

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Zusammenfassung

Die gastroösophageale Refluxkrankheit (GERD) ist häufig. Die Standardbehandlung erfolgt mit Allgemeinmaßnahmen und einem Protonenpumpeninhibitor (PPI). Von einer therapierefraktären GERD spricht man dann, wenn Symptome unter einer Standarddosis eines PPI nicht innerhalb von 8 Wochen zufriedenstellend kontrolliert sind. Die Heilung einer schweren Refluxösophagitis kann durchaus einen längeren Behandlungszeitraum erforderlich machen. Bei therapierefraktärer GERD ist ein stratifiziertes Vorgehen erforderlich, um diagnostische Irrungen und therapeutische Wirrungen zu vermeiden. Wichtige Ursachen sind eine falsche Diagnose, eine inadäquate Säuresuppression und eine pathophysiologische Grundlage, bei der die Säure eine untergeordnete Rolle spielt. Nach Ausschluss einer anderweitigen ösophagealen oder extraösophagealen Ursache sollte zunächst die säurehemmende Therapie optimiert werden. Bei anhaltender Problematik ist dann eine funktionelle Diagnostik angezeigt, am besten mit einer kombinierten pH-Metrie und Impedanzmessung. In Abhängigkeit vom Ergebnis kommen als therapeutische Optionen im Wesentlichen eine Intensivierung und Optimierung der antisekretorischen Therapie, eine Beeinflussung der transienten Relaxationen des unteren Ösophagussphinkters, eine Modulation der ösophagealen Sensitivität und eine operative Rekonstruktion der gastroösophagealen Antirefluxbarriere in Betracht.

Abstract

Gastro-esophageal reflux disease (GERD) is common. Standard treatment includes lifestyle measures and proton pump inhibitors (PPIs). GERD is considered to be refractory to treatment when a standard dose of PPI fails to sufficiently control symptoms within 8 weeks. Severe reflux esophagitis may require a longer period of treatment. In the event of therapy-resistant GERD, a stratified approach is needed if diagnostic errors and therapeutic confusion are to be avoided. Major stumbling blocks are misdiagnosis, inadequate acid suppression, and a pathophysiological situation in which acid plays only a minor role. When other potential esophageal or extra-esophageal causes have been excluded, the first step is to optimise acid inhibition measures. If problems nevertheless persist, a functional diagnostic workup is indicated, preferably using a combination of pH-metry and impedance monitoring. Depending on the outcome, the therapeutic options that are then most likely to be useful are intensification and optimisation of the antisecretory treatment, measures aimed at relaxing the lower esophageal sphincter, modulation of esophageal sensitivity, and surgical reconstruction of the gastro-esophageal antireflux barrier.

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Interessenkonflikt

Professor Labenz weist auf folgende Beziehungen hin: Vortragshonorare, Beratung, Unterstützung von AstraZeneca.

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Authors and Affiliations

  1. Medizinische Klinik, Ev. Jung-Stilling-Krankenhaus, Wichernstr. 40, 57074, Siegen, Deutschland

    J. Labenz

  2. Chirurgische Klinik und Poliklinik, TU München, Ismaninger Str. 22, 81675, München, Deutschland

    H. Feußner

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  2. H. Feußner
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Correspondence to J. Labenz or H. Feußner.

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Labenz, J., Feußner, H. Therapieresistente Refluxkrankheit. Gastroenterologe 4, 393–402 (2009). https://doi.org/10.1007/s11377-009-0290-6

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