How to treat persistent GERD symptoms when PPI therapy fails

Persistent GERD symptoms can be frustrating for both patients and practitioners, especially when standard treatments fall short. For this patient, symptoms are still present despite high-dose PPI therapy and modifications made to diet and exercise. 

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A 44-year-old man has persistent daily heartburn and regurgitation despite strict adherence to twice-daily PPI therapy and lifestyle modifications (weight loss, diet changes, head-of-bed elevation). Upper endoscopy showed mild esophagitis but no strictures or Barrett’s.

He has no dysphagia or alarming symptoms. Symptom burden significantly affects his quality of life, and he is eager for alternatives beyond medication.

Questions for consult 

 Consults

Key takeaways about treating persistent GERD symptoms: 

• pH-impedance testing can identify non-acid reflux
  When GERD symptoms persist despite PPIs, pH-impedance testing helps detect both acid and non-acid reflux, guiding more targeted treatment.
  
• Adjunct therapies may improve symptom control
  Adding H2 blockers, alginates, or trying newer PPIs like Vonoprazan may help patients who don’t respond to standard therapy.
• Consider psychological and surgical factors
  In some cases, anxiety may contribute to persistent symptoms. Surgical options like fundoplication can help, but outcomes vary.
  

Internal Medicine

"I would arrange for 24-hour pH monitoring to measure gastric acid levels and impedance monitoring to detect non-acid reflux. I would also test for H. pylori."

Family Practice

"Further testing should be done if it would be covered. Insurance coverage is an issue. I wonder about Nissen Fundoplication appropriateness- surgical referral? Although I have had patients with this same stubborn complaint, and after all the treatments AND a fundoplication, the relief was short-lived. In that instance, the patient had significant anxiety, and I tend to think his symptoms were driven partly by his anxiety. One has to at least consider if this is psychosomatic?"

Gastroenterology

"I’d order esophageal pH-impedance testing when symptoms persist despite high-dose PPIs and lifestyle changes, especially if the scope doesn’t show much damage. This helps me figure out if acid or non-acid reflux is causing the problem or if it’s something else. To help with symptoms, I might try adding an H2 blocker at night or using alginates to protect the esophagus.

If reflux isn’t the main issue, low-dose antidepressants could ease discomfort. If tests confirm reflux, surgery or other procedures might be worth discussing."

Gastroenterology

"In the differential would be included: non-Erosive GERD, inadequate PPI therapy (i.e., was a more effective PPI like Dexilant or most especially Vonaprazan tried?)

Is the hypercalcemia or Zollinger-Ellison's involved? At this point, rather than further testing, I would try a course of Voquenza, check serum Ca+ and Gastrin levels, and go further with impedance testing only if an inadequate response is had."

Unspecified/Other

"He sounds like a good candidate for pH impedance testing since he has symptoms despite doing lifestyle changes and taking PPI twice a day. It detects both acidic and non-acidic reflux, as well as gas and mixed refluxes.

This is crucial because non-acidic reflux can cause symptoms that are indistinguishable from acidic reflux, even in patients taking PPIs. Adding other medications like histamine-2 receptor antagonists (H2 blockers), alginates, or GABA agonists may be worth considering."

To explore more peer insights on managing persistent GERD symptoms, or share your own approach, read the full case on Healthcasts.