GERD 9: PPI-Refractory Heartburn and Series SynthesisEpisode keywords: PPI refractory GERD workup, Spechler NEJM 2019 GERD trial, functional heartburn proportion, fundoplication refractory GERD outcomes, ACG refractory GERD algorithm, GERD diagnosis algorithm, desipramine GERD, baclofen refractory heartburn, systematic GERD workupEpisode SummaryThe Spechler NEJM 2019 trial enrolled 366 patients with heartburn persisting on PPIs and systematically worked up every one before randomizing anyone. The result: only 21% had truly PPI-resistant, reflux-related heartburn. More than one in four had functional heartburn with no reflux relationship. Eleven percent responded to PPI optimization alone before the workup even started. The trial shows that systematic evaluation is not a prerequisite for surgery -- it is the treatment. This final episode covers the trial data, the ACG refractory GERD algorithm, and a full synthesis of all nine episodes into the framework boards are actually testing.Key TopicsSpechler et al., NEJM 2019: VA study, 366 patients with heartburn persisting on PPI therapy. Step 1: optimize PPI to omeprazole 20 mg twice daily taken 30 to 60 minutes before breakfast and dinner for two weeks. Result: 42 patients (11.5%) responded to optimized PPI alone, never reaching the formal workup. Step 2: the non-responders underwent endoscopy with biopsies, esophageal manometry, and combined impedance-pH monitoring on PPI therapy. Final distribution: 70 patients (19%) unable or unwilling to complete workup; 54 (15%) excluded for miscellaneous reasons; 21 (6.3%) had non-GERD esophageal disorders; 99 (27%) had functional heartburn (normal acid exposure, negative SAP); and 78 (21%) had truly PPI-resistant reflux-related heartburn. One in five patients. That is the denominator for surgical candidates.Randomized comparison in confirmed reflux-related refractory heartburn: 78 patients randomized to three arms. Laparoscopic Nissen fundoplication achieved 67% treatment success (at least 50% improvement in GERD-HRQL at one year). Active medical therapy (omeprazole plus baclofen plus desipramine) achieved 28%. Control medical therapy (omeprazole plus placebo baclofen plus placebo desipramine) achieved 12%. Surgery was significantly superior to both medical arms. For the correctly diagnosed patient, fundoplication works. The implication: if you had operated on all 366 patients without the workup, you would have operated on the 27% with functional heartburn, the 11.5% who just needed proper PPI instructions, and the 6.3% with non-GERD disorders. Systematic evaluation is what makes surgery successful, not surgery itself.ACG algorithm for refractory GERD: Step 1 -- optimize PPI (correct timing, twice daily, consistent use). Step 2 -- endoscopy. If normal endoscopy and no prior objective GERD confirmation, proceed to ambulatory pH monitoring off PPIs. Step 3 -- if GERD is established and symptoms persist on twice-daily PPI, proceed to combined impedance-pH monitoring on PPIs. For extraesophageal symptoms, antireflux procedures require objective reflux evidence before proceeding.

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