title: Refractory gastroesophageal reflux disease.
abstract: BACKGROUND
  Gastroesophageal reflux disease (GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Its pathophysiology, diagnosis and treatment have frequently been analyzed but it is interesting to review some aspects of the GERD refractory patients to the proton pump inhibitors treatment. The treatment encompasses behavioral measures and pharmacological therapy. The majority of the patients respond well to proton pump inhibitors treatment but 20%-42% of them may not do so well. Patients who are unresponsible to 4-8 weeks' treatment with proton pump inhibitors (omeprazole, pantoprazole, rabeprazole, lansoprazole, esomeprazole, pantoprazole-Mg) might have so-called refractory GERD.
  
  
  RESULTS
  In some cases the patients are not real refractory because either they do not have GERD or the disease was not correctly treated, but the term refractory is still employed. Although debatable, the Brazilian GERD Consensus based upon evidences recommends as first step in the diagnosis, the upper digestive endoscopy to exclude the diagnosis of peptic ulcer and cancer and in some cases identify the presence of esophageal mucosa erosions.
  
  
  CONCLUSIONS
  The main causes of the so-called refractory GERD are: (1) functional heartburn; (2) low levels of adherence to proton pump inhibitors treatment; (3) inadequate proton pump inhibitors dosage; (4) wrong diagnosis; (5) co-morbidities and pill-induced esophagitis; (6) genotypic differences; (7) nonacid gastroesophageal reflux; (8) autoimmune skin diseases; (9) eosinophilic esophagitis.
authors: University of Sao Paulo School of Medicine, Rua Itapaiuna 1165, São Paulo, SP, Brazil. joaquim.prado@uol.com.br
authors: Joaquim Prado P
authors: JP
authors: Moraes-Filho
mesh_terms: D003951:Diagnostic Errors; D016099:Endoscopy, Gastrointestinal; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D006801:Humans; D055118:Medication Adherence; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D017211:Treatment Failure
chemical_list: D054328:Proton Pump Inhibitors