The patient who anchors this episode is on twice-daily PPI and still symptomatic. The question is not how to escalate, it is what they actually have. Most PPI-refractory patients do not have refractory acid reflux; they have reflux hypersensitivity or functional heartburn, and each has its own treatment that acid suppression and surgery do not touch. The case. A patient on twice-daily PPI for months still has heartburn. Off-PPI pH testing shows an acid exposure time of 3 percent with a positive symptom association. What is the diagnosis, and why is more acid suppression or surgery the wrong next move? Topics coveredReflux monitoring as the test that assigns the diagnostic bucketLyon Consensus 2.0: acid exposure time thresholds and supportive metricsThe on-PPI versus off-PPI decision, driven by what you are trying to proveThe four buckets: confirmed GERD, reflux hypersensitivity, functional heartburn, and no refluxReflux hypersensitivity: normal acid exposure, positive symptom associationFunctional heartburn: normal acid exposure, negative symptom association, neuromodulator treatmentObjective reflux documentation required before antireflux surgeryMatching the operation to the anatomy: fundoplication, magnetic sphincter augmentation, TIFWhy most PPI-refractory patients are not refractory acid reflux Key decisionsPPI-refractory heartburn is a sorting problem, not an escalation problem: run the Lyon framework before adding acid suppression or referring for surgeryOff-PPI testing proves whether the patient has GERD at all; on-PPI testing evaluates a known-GERD patient with breakthrough symptoms. The question you are asking picks the protocolFunctional heartburn (normal AET, negative symptom association) is treated with a neuromodulator, not more PPI and not surgeryAntireflux surgery requires documented objective reflux first: operating on functional heartburn reliably failsReflux hypersensitivity (normal AET, positive symptom association) gets combined neuromodulator plus acid suppression For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: the PPI-refractory patient (01:30) - Reflux monitoring and the Lyon framework (05:00) - On-PPI versus off-PPI testing (08:00) - The four diagnostic buckets (12:00) - Antireflux surgery: matching operation to anatomy (18:00) - Functional heartburn and reflux hypersensitivity

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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