title: Management of the patient with incomplete response to PPI therapy.
abstract: Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. p-kahrilas@northwestern.edu
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kahrilas
authors.forename: Guy
authors.initials: G
authors.lastname: Boeckxstaens
authors.forename: Andre J P M
authors.initials: AJ
authors.lastname: Smout
mesh_terms: D016099:Endoscopy, Gastrointestinal; D050782:Esophageal pH Monitoring; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000601:surgery*; D006356:Heartburn / Q000188:drug therapy; D006801:Humans; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*
chemical_list: D054328:Proton Pump Inhibitors
keywords: Ambulatory oesophageal pH monitoring; Ambulatory oesophageal pH-impedance monitoring; Gastroesophageal reflux disease; Oesophagus; Proton pump inhibitors; Visceral hypersensitivity