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Lookup NU author(s): Emeritus Professor Amritpal Hungin
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0).
© 2025 The Author(s). Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd. Background: Reflux-like symptoms and reflux oesophagitis are often perceived as having the same acid-related aetiology and responsiveness to antisecretory therapy. However, the frequency of residual symptom reporting on proton pump inhibitor (PPI) therapy suggests the two entities have some differential pathophysiological determinants requiring distinct management approaches. Aims: To examine the complexities of reflux-like symptom pathophysiology and strategies that may be used to target contributing factors beyond acid reflux. Methods: A panel of ten expert clinicians (primary care, gastroenterology and psychology) held a series of online meetings to share perspectives on the underlying contributors to, and management of, reflux-like symptoms when PPIs are ineffective or provide partial relief. This review summarises the agreed key themes that emerged from the expert discussions. Results: While degradation of the anti-reflux barrier dominates in reflux oesophagitis, cognitive-affective, behavioural, and other psychosocial factors can play a major role in symptom persistence. These require individualised management strategies, beginning with education on the gut-brain connection and expectation setting with regard to PPI therapy. A detailed clinical history and patient-reported outcome tools that measure symptom burden and associated anxiety/hypervigilance can help guide management using brain-gut behavioural therapies, supported diet/lifestyle modification, diaphragmatic breathing, weight loss, and/or on-demand symptom control measures according to a patient's specific needs. Conclusions: A paradigm shift in reflux-like symptom management is required such that acid suppression is viewed as one of several interventions that can be utilised as part of a phenotype-driven, individualised approach to care that acknowledges the multiple contributors to symptom burden.
Author(s): Kahrilas PJ, Keefer L, Yadlapati R, Anastasiou F, Heidelbaugh JJ, Howden CW, Mendive JM, Savarino EV, Udrescu M, Hungin APS
Publication type: Review
Publication status: Published
Journal: Alimentary Pharmacology and Therapeutics
Year: 2025
Volume: 61
Issue: 9
Pages: 1437-1446
Print publication date: 01/05/2025
Online publication date: 01/04/2025
Acceptance date: 23/03/2025
ISSN (print): 0269-2813
ISSN (electronic): 1365-2036
Publisher: John Wiley and Sons Inc
URL: https://doi.org/10.1111/apt.70115
DOI: 10.1111/apt.70115
Data Access Statement: Data sharing is not applicable to this article as no new data were created or analyzed in this study.
