Drug failure on twice-daily acid suppression is not refractory reflux, it is a reason to work the patient up, and the workup usually turns up something other than reflux. The Lyon Consensus framework, with its acid-exposure cutoffs and symptom-association tests, sorts persistent symptoms into confirmed reflux, borderline, reflux hypersensitivity, and functional heartburn. Antireflux surgery is matched to proven reflux and to motility, and it is reserved for the small group left standing after the mimics are excluded. Topics covered PPI failure is a different diagnosis, not breakthrough reflux Lyon Consensus: proof, support, and evidence against Testing on-drug versus off-drug depends on what you must prove Four buckets: confirmed, borderline, hypersensitivity, functional heartburn Matching wrap type to esophageal motility Magnetic device, incisionless fundoplication, and bariatric options The ordered refractory workup and its mimics Atypical presentations and weak reflux linkage Key decisions Acid exposure time above six percent is proof-level reflux; under four percent is evidence against; four to six is borderline and leans on supporting measures Test off-drug (hold about a week) to prove reflux exists; test on-drug with impedance to characterize breakthrough when reflux is already known Functional heartburn gets a neuromodulator alone; reflux hypersensitivity gets a neuromodulator plus acid suppression; the most common cause of fundoplication failure is operating on functional heartburn Full 360-degree wrap for normal motility, partial two-thirds wrap for weak or scleroderma esophagus; a full wrap on a weak esophagus causes dysphagia Magnetic bead device is excluded by hernia over three centimeters, BMI over thirty-five, Barrett's, severe esophagitis, or absent peristalsis; incisionless fundoplication needs a hernia under two centimeters Gastric bypass is the antireflux operation of choice in the obese refluxer; avoid the sleeve, and BMI over thirty-five independently predicts fundoplication failure PPIs are prodrugs: dose thirty to sixty minutes before meals, and confirm timing before calling a patient refractory Take high and low biopsies even on a normal-looking scope; eosinophilic esophagitis is fifteen or more eosinophils per high-power field For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The patient whose reflux drug has failed (00:57) - The Lyon Consensus framework (02:25) - Testing on-drug versus off-drug (03:15) - The four diagnostic buckets (04:16) - Proving reflux before surgery (05:22) - Matching wrap type to motility (07:57) - The obese refluxer and bariatric surgery (10:03) - The ordered refractory workup and its mimics

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