PD06.09. Second-Line Treatment Efficacy in Functional Heartburn Based on HRM and MII-pH Evaluation

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ID: 326124
2026
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Abstract
Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Functional heartburn (FH) accounts for approximately half of patients with proton pump inhibitor (PPI)- or vonoprazan-refractory non-erosive reflux symptoms. However, the clinical characteristics of FH and the efficacy of second-line therapies remain incompletely understood. We evaluated patient characteristics and treatment outcomes following physiological evaluation. Methods Between September 2013 and December 2025, we retrospectively reviewed patients with PPI- or vonoprazan-refractory heartburn who underwent high-resolution manometry (HRM) and multichannel intraluminal impedance–pH (MII-pH) monitoring after discontinuation of acid-suppressive therapy at our institution. FH was diagnosed according to the updated Lyon Consensus 2.0 criteria. Clinical characteristics were compared between FH and true NERD. Symptom severity was assessed using the Frequency Scale for the Symptoms of GERD (FSSG). We evaluated comorbid conditions diagnosed after FH identification and analyzed the type and efficacy of second-line therapies. Treatment response was defined as a ≥50% reduction in FSSG score. Results Among 303 MII-pH studies, 125 patients were evaluated off acid-suppressive therapy for refractory heartburn, and 47 (38%) were diagnosed with FH. Compared with true NERD, FH patients were more often female (58.4% vs. 29.6%, p=0.008), younger (59.0 vs. 69.0 years, p=0.03), and had lower BMI (21.3 vs. 23.7, p<0.001). The GSRS indigestion score was higher in FH (10.0 vs. 8.5, p=0.047). Fifteen patients were subsequently diagnosed with psychiatric, cardiovascular, otolaryngological, or orthopedic conditions, with symptom improvement following appropriate treatment. Among 15 patients receiving second-line therapy with evaluable FSSG scores, 10 (66.7%) achieved ≥50% symptom improvement. SSRIs significantly reduced median FSSG scores from 20 (17.5–26.0) to 7.0 (4.0–10.5) (p=0.018). Acid-suppressive therapy was discontinued in 61.7% of FH patients. Conclusion FH demonstrated distinct clinical characteristics compared with true NERD. Following comprehensive physiological evaluation using HRM and MII-pH, second-line therapies—particularly SSRIs—were associated with substantial symptom improvement. Physiologically guided, individualized management may improve outcomes in patients with FH.
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Authors Hiromi Arakawa, Tomoaki Matsumura, Tomomi Ozaki, Miyuki Iwasaki, Michiko Sonoda, Jun Kato
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Journal diseases of the esophagus : official journal of the international society for diseases of the esophagus
Year 2026
DOI
10.1093/dote/doag077.121
URL
https://academic.oup.com/dote/article-pdf/39/Supplement_1/doag077.121/70760868/doag077.121.pdf
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