GERD and Refractory Reflux

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 3.1: Antireflux barrier physiology and pathogenesis

  GERD is a barrier failure problem before it is an acid problem.

• Section 3.2: Endoscopic findings and Los Angeles classification

  The endoscopic grade of esophagitis determines treatment intensity, the need for repeat endoscopy, and eligibility for surgery.

• Section 3.3: Acid suppression therapy ladder and PPI safety

  Acid suppression is the main GERD therapy, and every agent acts on the parietal cell.

• Section 3.4: pH-impedance testing and the Lyon Consensus

  Reflux monitoring is the test that decides whether a patient with persistent symptoms actually has GERD, has a borderline reflux burden that may or may not explain the symptoms, has reflux hypersensitivity, or has functional heartburn.

• Section 3.5: Antireflux surgery and endoscopic therapies

  The operation for GERD is selected on motility status, hiatal hernia size, body mass index, and patient preference.

• Section 3.6: Refractory GERD evaluation and management

  Refractory GERD is defined by persistent symptoms on optimized acid suppression.

Podcast episodes

1. 01

   GERD and Refractory Reflux: Erosive Esophagitis

   Reflux is a failure of the barrier between stomach and esophagus before it is a problem of acid, and the episode follows two patients through that idea. A man with grade C erosive esophagitis and a hiatal hernia shows what the Los Angeles grade decides, why transient sphincter relaxations, the hernia, lying flat, and obesity cause reflux, and why H2 blockers fade. It then covers PPI timing and speed, vonoprazan, maintenance, and the safety of long-term PPI use. A woman with non-erosive reflux shows how to step down and confirm the diagnosis. The episode closes with board traps.

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2. 02

   GERD and Refractory Reflux: Workup and Surgery

   Most heartburn that persists on a PPI is not refractory acid reflux, so this episode treats that label as a diagnosis to be tested. The workup starts with how the drug is taken, then intensifies acid suppression, then adds endoscopy with biopsies and the reflux test that fits the patient, read as one of four diagnoses. It then covers medical options for proven reflux that persists and the need for objective testing in extraesophageal symptoms. The second half turns to antireflux surgery: proof of reflux first, the three-test workup, what a wrap rebuilds, matching the wrap to motility, the magnetic ring and transoral options, and the effect of weight.

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3. 03

   GERD and Refractory Reflux: Strictures and Rings

   The organizing idea is that reflux patients whose food sticks fall into two groups, and the pattern of dysphagia tells them apart before any test. A progressive, worsening narrowing in a patient with decades of untreated reflux is a peptic stricture, even when heartburn improves. The episode covers the endoscopy and biopsies it requires, gradual dilation by the rule of threes, and lifelong twice-daily PPI with timing checks and a repeat endoscopy after severe esophagitis heals. It then turns to the man with intermittent steak impactions and a Schatzki ring, which is fixed rather than tightening, so it is fractured with one large dilator instead of stretched.

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Key topics

• ·Los Angeles grading of esophagitis
• ·What grade C and D decide
• ·Hiatal hernia and the reflux barrier
• ·Transient lower esophageal sphincter relaxations
• ·Acid pocket, nighttime reflux, and obesity
• ·H2 blocker tachyphylaxis
• ·PPI timing, speed, and relative potency
• ·Vonoprazan as a potassium-competitive acid blocker
• ·Maintenance versus step-down therapy
• ·Long-term PPI safety and drug interactions
• ·PPI timing and optimization
• ·Intensifying acid suppression
• ·Endoscopy with two-level biopsies
• ·Off-PPI versus on-PPI reflux testing
• ·Lyon consensus acid exposure time
• ·Reflux hypersensitivity and functional heartburn
• ·Mimics: rumination and supragastric belching
• ·Baclofen and alginates
• ·Extraesophageal symptoms and testing
• ·Surgical workup and choice of wrap
• ·Magnetic ring and transoral fundoplication
• ·Obesity and gastric bypass
• ·Dysphagia pattern in peptic stricture
• ·Why improving heartburn is a warning
• ·Biopsies for cancer and eosinophilic esophagitis
• ·Los Angeles grade C esophagitis and hernia size
• ·Dilation and the rule of threes
• ·Twice-daily PPI and correct timing
• ·Repeat endoscopy for hidden Barrett esophagus
• ·Schatzki ring versus stricture