Rethinking Long-Term PPI Therapy in GERD: A Narrative Review from a Microbial Ecology Perspective Beyond Acid...

Area of Science:

• Gastroenterology and Microbiology
• Investigating the complex interplay between host, microbes, and disease.
• Focusing on esophageal microbial ecology and its role in gastrointestinal disorders.

Background:

• Gastroesophageal reflux disease (GERD) is traditionally viewed through an acid-centric model.
• Proton pump inhibitors (PPIs) are primary GERD treatments, but many patients remain symptomatic.
• GERD is increasingly recognized as multifactorial, involving reflux barrier, mucosal defense, immune responses, and microbiota.

Purpose of the Study:

• To review current evidence on acid suppression, esophageal microbial ecology, and host-microbe interactions in GERD.
• To explore the potential of microbiota-targeted therapeutic strategies for GERD.
• To provide an integrated overview of these complex relationships.

Main Methods:

• Conducted a narrative literature review using electronic databases (PubMed, Scopus).
• Prioritized recent and clinically relevant studies without formal time restrictions.
• Qualitatively synthesized evidence to provide an integrated overview.

Main Results:

• The esophagus harbors a microbial ecosystem influencing mucosal homeostasis.
• GERD and Barrett's esophagus show shifts toward pro-inflammatory Gram-negative anaerobic bacteria.
• Long-term PPI use alters gut microbiota, increasing certain taxa and reducing beneficial bacteria, potentially linked to dysbiosis.

Conclusions:

• GERD is a multifactorial condition where acid suppression impacts esophageal microbial ecology.
• Alterations in the gut microbiome due to PPIs may influence GERD pathogenesis and treatment outcomes.
• Understanding these interactions can lead to integrated, personalized therapeutic strategies targeting the microbiota.