Refractory GERD — Management per Lyon Consensus 2.0 & ACG Guidelines
Comprehensive education on diagnosing, phenotyping, and managing GERD and refractory GERD using objective physiologic criteria
- Apply the Lyon Consensus 2.0 framework to diagnose GERD using objective physiologic evidence
- Distinguish GERD phenotypes: ERD, NERD, hypersensitive esophagus, functional heartburn, and LPR
- Select and interpret the correct diagnostic test (pH, pH-impedance, manometry, endoscopy) for each clinical scenario
- Implement ACG step-wise management from lifestyle modification through PPI optimization
- Systematically evaluate and manage refractory GERD without inappropriate treatment escalation
- Identify appropriate candidates for endoscopic and surgical anti-reflux procedures
Sections
Definition, epidemiology, mechanisms
Gastroesophageal reflux disease (GERD) is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. It affects ~20% of the US population and is among the most common GI conditions managed in gastroenterology practice.
~20%
US adult prevalence
$24B+
Annual US healthcare costs
30–40%
PPI non-response rate in "GERD"
Transient LES Relaxations (TLESRs)
Most common mechanism — inappropriate relaxation of the LES unrelated to swallowing, allowing gastric contents to reflux.
Low Basal LES Pressure
Sustained hypotension of the LES enables passive acid reflux, particularly when associated with hiatal hernia.
Hiatal Hernia
Disrupts the anti-reflux barrier, impairs esophageal acid clearance, creates an acid pocket above the diaphragm.
Impaired Esophageal Clearance
Reduced peristalsis prolongs esophageal acid contact time, increasing mucosal damage.
Esophageal Hypersensitivity
Central and peripheral sensitization lowers the threshold for reflux perception — key in functional heartburn and NERD.
Delayed Gastric Emptying
Found in ~40% of GERD patients; increases gastric volume and pressure driving reflux.
Modifiable
- Obesity (central adiposity)
- Dietary triggers (fatty foods, caffeine, chocolate, alcohol, mint)
- Smoking
- Large meal portions
- Recumbent position after meals
- Certain medications (CCBs, nitrates, anticholinergics, bisphosphonates)
Non-modifiable
- Hiatal hernia
- Pregnancy
- Connective tissue disorders (scleroderma)
- Genetic predisposition
- Age (reduced LES tone with aging)
- Male sex (erosive disease more common)