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“Refractory GERD: a complicated puzzle”

The persistence of symptoms in GERD patients despite adequate PPI therapy is a rather common and sometimes frustrating problem. Two articles in this January issue of Diseases of the Esophagus deal with this topic, offering some insight on the mechanisms underlying the condition.

In the first article by Mandalyia et al (Survey of findings in patients having persistent heartburn on PPI therapy), 100 patients with GERD symptoms refractory to PPI were assessed by means of combined impedance-pH study and the Symptom Sensitivity Index (SSI). Patients were then  divided into 4 groups on the basis of these findings, i.e.  cases with acid reflux, those with non-acid reflux, those with a positive SSI and those with normal reflux parameters; the Authors suggested that the normal treatment strategy of increasing the PPI dose when patients remain symptomatic might only be appropriate for some patients.

In the second study by DeBortoli et al. (Lower pH value of weakly acidic refluxes as determinants of heartburn perception in GERD patients with normal esophageal acid exposure), the Authors focused on patients  with  a positive Symptom Association Probability (SAP) index and Symptom Index for weakly acidic reflux, finding that a lower nadir pH (in the range of pH 4 to 5.5) during non-acid reflux was associated with symptom perception, suggesting that a higher concentrations of hydrogen ions may be an important symptom trigger, even for “non-acid” reflux in this complex condition.