HotButton DiagnosisDespite lifestyle modifications along with the use of anti-reflux medications, some people with gastroesophageal reflux disease (GERD) continue to have reflux symptoms. Approximately 10-40% of people with GERD fail to respond symptomatically, either completely or partially. We may refer to this as refractory GERD and our approach to these patients is discussed below.

Most patients who do not respond to reflux medications have either functional heartburn, or non-erosive reflux disease (NERD). The following are conditions or reasons why someone may not respond to usual treatments.

  • Improper dosing
    PPIs should be taken as directed by your physician.
  • Compliance
    Many patients take their reflux medication only as needed, and although this could be effective for some, if symptoms tend to be persistent or recurrent, then medication should be taken daily as scheduled by the Physician. Altering dosage, splitting the dosing, or adding other medications should be discussed with your Physician.
  • Functional Heartburn
    This is defined someone having symptoms of GERD, such as retrosternal burning or pain with absence of GERD as a cause both endoscopically and by biopsy, along with the absence of an esophageal motility disorder. Many of these patients have increased esophageal sensitivity to anything topical which may occur with occasional reflux of acid, pepsins or foods, etc.
  • Alkaline reflux (non-acid reflux)
    Exposure to the esophageal lining of non-acid related materials could cause GERD. This might include certain foods, pepsins, enzymes, caffeine, etc.
  • Bile acid reflux
    Bile, which is produced in the liver and is necessary to break down and digest our food, is released in the small intestine beyond the stomach. Bile is not acidic, rather alkaline, but it can be very irritating to the gastric and esophageal lining. In certain cases, one might reflux bile upward, in particular in those who have had any type of gastric surgery, decreased gastric emptying time (gastroparesis), abdominal adhesions, or severe constipation. It will not respond to acid reduction therapy such as H2 Blockers or PPIs. Sucralfate has been helpful in this situation.
  • H. Pylori
    Helicobacter Pylori positive patients increase in gastritis and heartburn, but not esophagitis. If there is gastritis at time of an upper endoscopy, it is now checked routinely.
  • NSAIDs
    Use of anti-inflammatory medications on a regular basis can not only lead to ulcers but increase symptoms of abdominal pain and GERD.
  • Eosinophilic Esophagitis (EOE)
    This is a condition seen frequently in young adulthood or in those in their 30s-40s. The esophagus scars down resulting in strictures, rings, furrows, and a decrease in distensibility. As a result, patients often present with difficulty swallowing and not uncommonly a food impaction where they cannot get something they ate to go up or down. EOE is thought to be a localized allergic-type reaction to a particular food group. This is diagnosed at the time of an upper endoscopy and biopsy, and often an esophageal dilation is necessary as well. Food allergy testing can help detect the particular food group that would need to be avoided, and specific medications are used to reduce the localized allergic reaction in the esophagus.
  • Delayed gastric empting (Gastroparesis)
    Patients with delayed gastric emptying are at high risk for GERD. This could be due to previous gastric or esophageal surgery, underlying medical conditions such as diabetes, certain medications, or it could just occur spontaneously.

GERD – Diagnostic Evaluation

Diagnostic studies should be undertaken for refractory GERD after reinforcement of lifestyle medication and compliance with medications. Sometimes doubling the dose of medication or switching to a different medication can be beneficial. The following are diagnostic studies that might be considered.

  • Upper Endoscopy (EGD)
    Patients who fail medical management or those who may have alarm symptoms (dysphagia, weight loss, upper GI bleeding) should have an EGD. This may allow the Physician to diagnose the cause for GERD as well as be therapeutic by performing biopsies or dilations if necessary. An Endoscopy is performed in an outpatient setting under IV sedation. Therefore, the patient is asleep and does feel anything during the procedure and awakens quickly afterwards. The Physician will speak with the patient and family afterwards relaying the finding and recommendations. Any biopsies that are taken will be available in 7-10 days after the procedure.
  • Esophageal PH testing
    Patients who fail to respond to double dose PPI therapy might be considered for PH testing to determine the acid levels in the esophagus. It is performed while the patient is off of their PPI reflux medication, and nowadays a wireless capsule (Bravo) is placed in the esophagus at the time of an upper endoscopy. The device is easy to place and the patient has no sensation of it being present. It records acid levels in the esophagus over a period of several days. It then falls off and is passed on through the GI tract without discomfort.
  • Esophageal Impedance Testing
    Used in combination with PH testing, this test can determine if there is continued acid exposure or nonacid exposure to the esophagus despite a PPI.
  • Esophageal Manometry
    This test measures the motility and wave contraction of the esophageal muscles. It has a limited value with GERD, but can be very helpful to determine causes for atypical chest discomfort and swallowing issues.

Midwest Heartburn Center
Midwest Gastroenterology
3601 NE Ralph Powell Rd.
Lee’s Summit, Missouri 64064