This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. As we have seen from the previous talk, about 10 to 50% of patients continue to have refractory symptoms in spite of PPI therapy. And then when they have symptoms, it is good to make a distinction about what exactly are the symptoms they have. One is refractory reflux-like symptoms, where the symptoms may or may not be GERD-related. And then the patients with refractory GERD symptoms, that is, the patients have a prior diagnosis of GERD, and now they have persisting symptoms, which may or may not be related to ongoing reflux or not. So these are like the overlap syndromes. And then finally, refractory GERD itself, where there is persisting objective evidence of GERD despite taking adequate PPI therapy. That is, they have either erosive esophagitis under endoscopy, or they have an abnormal pH test or pH impedance test on PPI therapy. And so these are the numbers which are good to know. For patients with persistent esophagitis on standard dose PPI therapy, in grade A esophagitis, 8% continue to have persistent esophagitis. In grade B, about 15%. And in grade C, about 20%. And in grade D esophagitis, almost 30% of the patients continue to have persistent esophagitis in spite of taking standard dose PPI therapy. So what are the causes of refractory PPI, GERD refractory to PPI? So it may be from several reasons. So one is that there is a true reflux going on. So there is a disrupted antireflux barrier, or there is increased transient LES relaxations, impaired esophageal clearance, or inadequate acid suppression, a significant hernia, obesity can contribute to refractory GERD. Then there is a reflux hypersensitivity, which we touched base on briefly before. So there is normal esophageal acid exposure, but physiologic reflux episodes cause the symptoms. And then there are patients who truly don't have GERD, but they have other esophageal disorders, which mimic GERD, like say, eosinophilic esophagitis, echolacea. And there could be underlying gastroparesis where patients continue to have acid regurgitation or foot regurgitation going on in spite of taking PPI's rumination where there is a voluntary regurgitation going on.

refractory symptoms

proton pump inhibitor therapy

persistent esophagitis

PPI-refractory GERD

underlying esophageal disorders