"Refractory GERD": acid, nonacid, or not GERD?

Gastroesophageal reflux disease (GERD) is a common condition with 44% of Americans surveyed reporting heartburn at least once a month and 20% once a week (1, 2). However, despite major advances in our understanding of this disease, management of GERD is still a challenge. Proton pump inhibitors (PPIs) are more effective than H2-receptor antagonists (H2RA) in the initial healing of erosive esophagitis, which provide symptom relief and maintenance (3). Due to its established efficacy and safety, PPI treatment is used as the initial "test" in diagnosing GERD in the absence of bleeding, anemia, weight loss, or dysphagia. A single dose of PPI provides adequate symptom relief in most patients; however, dose escalation to twice a day may be needed in some. Patients unresponsive to PPI therapy are often labeled as having "refractory GERD." However, this term is poorly defined and has a different meaning in different countries. More importantly, the cause of "refractory GERD" is poorly understood.