Treatment-Resistant GERD

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For most of the 25–30%1 of the population who suffer from gastroesophogeal reflux disease (GERD), lifestyle changes and medication are quick to relieve symptoms. But sometimes physicians will encounter patients whose symptoms don't improve or only partially resolve with treatment. Below, Bennett Roth, MD, a gastroenterologist at the Ronald Regan UCLA Medical Center in Los Angeles, discusses those cases and what physicians can do to help these patients.


There are many patients who respond well to lifestyle changes and/or medications, such as proton pump inhibitors, to control GERD. However, there is a subset of patients who are not helped by these treatments. What are the most common medical reasons behind a patient's failure to respond to traditional interventions for GERD?
Typically, if a patient has heartburn as the major and sole complaint, he or she is almost always helped by an acid-reducing regimen using medication and lifestyle changes. But this is not always true for patients who experience additional symptoms. Some patients may regurgitate food when they bend forward, in addition to the burning sensation caused by heartburn. In these cases, the medication may relieve the heartburn, but the regurgitation will persist. This indicates that the individual may have mechanical problems related to their esophagus (e.g., a large hiatal hernia or incompetent lower esophageal sphincter), which require a different or additional treatment approach.

Another common scenario is that the patient is taking his or her medication incorrectly. We see this all the time. A doctor will instruct a patient, or the patient will decide independently, to take their medication at night, rather than in the morning, because some think it will help alleviate nighttime symptoms. But in fact, it just reduces the effectiveness of the drug. The medication must be taken up by the parietal cells in order to be effective, and the half-life of a typical proton pump inhibitor is 90 minutes. Since the parietal cells and proton pumps are activated by meals, by the time the patient has reached breakfast, he or she is not getting optimal coverage from the drug. Many physicians don't even realize that taking the medicine at the wrong time of day can impair its effectiveness.

In a minority of cases, another medication or disease may interfere with GERD treatment. But most often, the reason why treatment fails — even when a patient appears to have traditional symptoms of reflux — is because the diagnosis is incorrect. Not everything that burns is GERD. Sometimes patients have problems with the motility of their esophagus, which allows food to sit and decompose, becoming acidic. This type of problem would not be helped by a proton pump inhibitor, because it has nothing to do with stomach acid production.

In another subgroup of patients, who may suffer from scleroderma or diabetes, the problem is caused by the stomach failing to empty correctly. In these cases, not only is it more likely that the stomach's contents will back up into the esophagus because it's overly full, but medication won't be digested effectively so it can work properly.