TY - JOUR T1 - Diagnosis and management of patients with reflux symptoms refractory to proton pump inhibitors JF - Gut JO - Gut SP - 1340 LP - 1354 DO - 10.1136/gutjnl-2011-301897 VL - 61 IS - 9 AU - Daniel Sifrim AU - Frank Zerbib Y1 - 2012/09/01 UR - http://gut.bmj.com/content/61/9/1340.abstract N2 - Approximately a third of patients with suspected gastro-oesophageal reflux disease are resistant or partial responders to proton pump inhibitors (PPIs). Many of these patients do not have gastro-oesophageal reflux disease, but suffer from functional heartburn or dyspepsia. The potential mechanisms underlying failure of PPI treatment in patients with reflux-related symptoms include persistence of isolated or mixed acid, weakly acidic, bile or gas reflux, impaired oesophageal mucosal integrity, chemical or mechanical hypersensitivity to refluxates and psychological comorbidity. After thorough clinical evaluation and failure of empirical changes in PPI dose regime, diagnostic investigations include endoscopy and reflux monitoring with pH or pH-impedance monitoring. If symptoms are clearly related to persistent reflux, baclofen, antireflux surgery or pain modulators can be considered. If not, pain modulators are the only currently available therapy. ER -