Refractory Gerd

Question 1

Refractory gerd

Answer 1

persistent bothersome heartburn (>2 times/week for 3 months) despite
BID PPI therapy.

Question 2

Causes

Answer 2

1-True GERD with Inadequate acid suppression,
2-GERD with non-acid reflux.
3-symptoms due to
an etiology other than GERD.

Question 3

Diagnosis

Answer 3

1-PPI dose optimization: Make sure the patient is taking PPI 30-60 minutes prior to meals.22
ƒ Consider adjunctive H2 receptor blocker therapies added at nighttime (e.g., famotidine).

Question 4

Diagnosis

Answer 4

2-Consider gastric emptying study in patients with refractory GERD symptoms.

Question 5

Diagnosis

Answer 5

3-Perform EGD (off PPI for 2-4 weeks) to exclude other etiologies and evaluate for erosive esophagitis
and Barrett’s esophagus. Perform biopsy the to rule out eosinophilic esophagitis (present in 1-8%)

Question 6

Diagnosis

Answer 6

If the patient has a normal endoscopy (or mild LA class A esophagitis), proceed with pH testing. If feasible, pH testing should be planned and performed immediately after EGD during the same session.
*patients with previously unproven GERD (no previous positive pH study or significant esophagitis
or Barrett’s): perform pH testing OFF PPI for 7 days.
* In patients with previously proven GERD: perform pH + impedance ON BID PPI.
ƒ The acid exposure time refers to the percent of time the pH is below 4
*Pathologic acid exposure time (>6%): This is consistent with GERD.
*Physiologic acid exposure time (<4%) with positive reflux-symptom association: This is consistent
with reflux hypersensitivity.

Question 7

Management

Answer 7

1-Truly refractory GERD and reflux related heartburn: Surgical therapy with Nissen
fundoplication appears to be more effective than medical therapy.

Question 8

Management

Answer 8

2-functional heart burn
*Discontinue PPI in purely functional heartburn.
*PPI can be continued in patients with functional
heartburn overlapping with GERD.
*Consider a trial of TCAs or SSRI
(fluoxetine 20 mg/day). Avoid anti-reflux surgery or endoscopic treatment.

Question 9

Management

Answer 9

3-Non-acid reflux is diagnosed by the detection of reflux episodes on impedance testing during which
the pH is > 4, and in association with GERD symptoms.
ƒ Management: Lifestyle modifications including weight loss, smaller meals.
ƒ Baclofen is a GABA-b receptor agonist. It decreases transient lower esophageal sphincter
relaxations. I

Question 10

Types of PH Metry

Answer 10

1-Esophageal pH Monitoring

Used to diagnose GERD (gastroesophageal reflux disease).
*24-hour catheter-based pH monitoring: A thin tube with pH sensors is inserted through the nose into the esophagus.
*Bravo wireless pH monitoring: A small capsule is attached to the esophageal wall via endoscopy; it transmits pH data wirelessly.
2. Impedance-pH Monitoring
Combines pH monitoring with impedance sensors to detect both acidic and non-acidic reflux, useful when patients have symptoms despite normal pH tests.
3. Gastric pH Monitoring
Measures acidity in the stomach to assess acid secretion levels, often used before or after anti-acid treatment or surgery.
4. Duodenal pH Monitoring
Used to measure bile reflux and assess alkalinity in the duodenum.