Treating Refractory Gastroesophageal Reflux Disease

When the Discomfort Returns

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The term refractory gastroesophageal reflux disease (refractory GERD) describes those patients who continue to have symptoms of gastroesophageal reflux despite standard treatment with proton pump inhibitors (PPIs).

Patients who experience refractory GERD usually fall into one of two groups:

  • Those who need more aggressive treatment
  • Those who have other causes of their reflux symptoms

More Aggressive Treatment of Refractory GERD

Needing more aggressive treatment does not mean the only option for these patients is surgery.

In fact, those who have the best outcomes from anti-reflux surgery are those who previously responded to medications. The refractory patients don't typically respond as well to anti-reflux surgery. This, however, doesn't mean surgery, such as fundoplication, wouldn't be an option. A physician will weigh the possible risks and complications of the surgery against the possible benefits and discuss with the patient whether surgery is a good option.

Some patients do not respond as well to the traditional doses of PPIs, and a physician may consider increasing the dose, as well as having patients go to twice daily doses instead of the typical once a day dosing.

It is important to control nighttime acid reflux. Taking an H2 blocker before bedtime has been shown to help with symptoms.

Other methods of controlling nighttime reflux include:

  • Sleeping with the head and shoulders elevated
  • Sleeping on the left side
  • Waiting two or three hours after eating to go to bed
  • Wearing loose-fitting bed clothes

Physicians may also prescribe the use of a promotility agent, such as Reglan, before meals and before bedtime to help decrease the risk of acid reflux.

Other Causes of Reflux Symptoms

When a patient doesn't respond to anti-reflux treatments, especially after more aggressive treatment is tried, other problems besides GERD may be at hand.

While GERD is the most common cause of reflux symptoms, it isn't the only cause. Other digestive disorders that can cause reflux include hiatal hernias and motility disorders.

The tests a physician may use to verify a diagnosis are:

The results of these tests will help a physician to decide on an appropriate treatment plan.

Refractory GERD is rare. If a patient experiences continued reflux symptoms despite treatment, a physician should be consulted. Discussing the type of symptoms experienced, their frequency, and keeping track of possible reflux triggers will aid in finding an appropriate treatment plan.


Kenneth R. DeVault M.D., F.A.C.G, Donald O. Castell M.D., M.A.C.G"Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease." doi: 10.1111/j.1572-0241.2005.41247.x. American College of Gastroenterology. 5 Dec 2007.

Ikuo Hirano, M.D.,1 Joel E. Richter, M.D., "ACG Practice Guidelines: Esophageal Reflux Testing." doi: 10.1111/j.1572-0241.2006.00936.x. American College of Gastroenterology. 5 Dec 2007.