Refractory gastrooesophageal reflux disease.

The introduction of proton pump inhibitors (PPIs) has facilitated the treatment of gastrooesophageal reflux disease (GORD) enormously; however, treatment of GORD still fails in a small proportion of patients. This small proportion of therapy-resistant patients encompasses a substantial part of the working load of physicians and has become a common clinical problem. A strong variability in acid-suppressive effect of PPI treatment exists depending on compliance, Helicobacter pylori status and genotype. Nocturnal acid breakthrough does not seem to be a major determinant of refractory GORD. Recent data, however, show that PPI-refractory GORD can result from nonacid reflux episodes. It is wise to reconsider the diagnosis of GORD in patients who are PPI-refractory. Most patients in whom a PPI is not effective do not have GORD, instead they suffer from other disorders such as functional dyspepsia. If after a thorough history is taken the suspicion of GORD is still high, the next step would be to perform upper endoscopy and reflux monitoring. In case patients truly have PPI-refractory GORD, therapy can be aimed at oesophageal hypersensitivity or a surgical solution can be sought.