title: Management of gastro-oesophageal reflux disease symptoms that do not respond to proton pump inhibitors.
abstract: OBJECTIVE
  Treatment-refractory gastro-oesophageal reflux disease (GERD) remains a significant problem in the gastroenterology clinic. In recent years, several studies have investigated the assessment and treatment of refractory GERD.
  
  
  RESULTS
  Patients presenting with 'refractory GERD' in fact represent a quite heterogeneous group consisting of those with ongoing reflux-related symptoms and those with reflux-unrelated problems such as functional heartburn, dyspepsia or even eosinophilic oesophagitis. The greatest symptom indicators of persistent true reflux are retrosternal burning and acid taste in the mouth alone. Combined pH-impedance studies allow detection of reflux regardless of pH, and weakly acidic reflux has been suggested as a mechanism of residual symptoms in some patients. The use of reflux-symptom association calculations may help to determine the symptom causation, but refinement and outcome studies are needed. New treatments of refractory GERD have been disappointing. Surgery remains an option in very carefully selected patients, but again better outcome studies are required.
  
  
  CONCLUSIONS
  Careful history and investigation is required in the assessment of the proton pump inhibitor (PPI)-refractory patient. Care to exclude alternative diagnoses is needed, and to phenotype those with reflux-related symptoms. Optimization of PPI therapy may help, as may surgery in selected patients.
authors.affiliation: Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.
authors.forename: Philip
authors.initials: P
authors.lastname: Woodland
authors.forename: Daniel
authors.initials: D
authors.lastname: Sifrim
mesh_terms: D050782:Esophageal pH Monitoring; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D005773:Gastroscopy; D006801:Humans; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D017211:Treatment Failure
chemical_list: D054328:Proton Pump Inhibitors