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How to manage refractory GERD

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 658–664 (2007)Cite this article

Abstract

Patients who are unresponsive to 4–8 weeks' treatment with PPIs twice daily might have so-called refractory GERD. The first investigation these patients should undergo is upper endoscopy to exclude a diagnosis of peptic ulcer disease or cancer and identify the presence of esophagitis. The presence of esophagitis in these patients is suggestive of a pill-induced injury, an autoimmune skin disease involving the esophagus, eosinophilic esophagitis or, less likely, a hypersecretory syndrome or a genotype that confers altered metabolism of PPIs. Refractory reflux syndromes associated with normal endoscopy findings are more problematic to diagnose and further testing may be required, including prolonged 48 h pH testing, impedance measurements (for nonacid reflux), esophageal manometry and gastric function tests. For patients with refractory GERD who do not have esophagitis, possible etiologies include nocturnal gastric acid breakthrough, nonacid GER, missed GER or other diseases such as achalasia, gastroparesis or functional heartburn.

Key Points

  • Approximately 25% of patients who have reflux symptoms fail to respond to twice-daily PPI treatment for 4–8 weeks; these patients are said to have 'refractory GERD'

  • The first test to perform in patients with refractory GERD is upper endoscopy, primarily to assess the presence or absence of esophagitis and other gastric pathology

  • Patients who have esophagitis most commonly have pill-induced injury, autoimmune skin disease associated with esophageal involvement, or eosinophilic esophagitis

  • Those patients who do not have esophagitis are more problematic to manage and have to undergo further tests, including prolonged pH monitoring, impedance testing for nonacid gastroesophageal reflux (GER), esophageal manometry or gastric function testing

  • Patients with refractory GERD without esophagitis might have nocturnal acid breakthrough, nonacid GER or missed acid GER, functional heartburn, or another disease such as achalasia or gastroparesis

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Figure 1: Algorithm used by the author for the management of patients with GERD.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Author notes

  1. Department of Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA jrichter@temple.edu

Authors and Affiliations

  1. Department of Medicine, JE Richter is Richard L Evans Professor and Chair, Temple University School of Medicine, Philadelphia, PA, USA.,

    Joel E Richter

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Competing interests

Joel E Richter is a member of speakers' bureaus for Astra-Zeneca and TAP.

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Richter, J. How to manage refractory GERD. Nat Rev Gastroenterol Hepatol 4, 658–664 (2007). https://doi.org/10.1038/ncpgasthep0979

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