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 pattern in a GERD vignette stratifies treatment intensity, surveillance obligations, and surgical candidacy in a single image.

• Section 3.3: Acid suppression therapy ladder and PPI safety

  The acid suppression ladder is the workhorse of GERD therapy and the mechanism of every step on it is parietal cell-centric.

• 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, and the surgical question is best approached as a matching problem rather than as a default referral.

• Section 3.6: Refractory GERD evaluation and management

  Refractory GERD is the workup run when a patient on optimized acid suppression continues to have symptoms, and the framework is mechanism-driven.

Podcast episodes

1. 01

   Mechanisms and Endoscopy

   GERD is a failure of the antireflux barrier, not acid overproduction. Most patients have a normal resting sphincter, so transient lower esophageal sphincter relaxations are the dominant mechanism, and a sliding hiatal hernia amplifies every failure mode at once. Endoscopy grades the erosive damage, sizes the hernia, and decides treatment intensity, surveillance, and surgical candidacy from one look.

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2. 02

   Acid Suppression Drugs

   Acid-suppressing drugs work only when their mechanism and timing line up. This episode explains why proton pump inhibitors heal erosive disease when histamine blockers fade, why wrong meal timing is the top cause of apparent PPI failure, and where vonoprazan changes the game.

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3. 03

   Refractory Lyon Surgery Functional

   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.

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Key topics

• ·Barrier failure, not acid excess
• ·LES plus crural diaphragm stacked as one valve
• ·Transient LES relaxations as the main mechanism
• ·Sliding hiatal hernia amplifies every failure mode
• ·Postprandial acid pocket and the alginate raft
• ·Failed acid clearance: supine, saliva loss, weak swallow
• ·Obesity, visceral pressure, and Barrett risk
• ·LA-grade erosive esophagitis and its consequences
• ·One pump, three switches: gastrin, histamine, acetylcholine
• ·H2 blockers fade as the cell ramps up
• ·PPIs are prodrugs that need meal-timed acid
• ·PPI potency ranking and escalation logic
• ·Nocturnal acid breakthrough on twice-daily dosing
• ·Vonoprazan as a mechanistically different acid blocker
• ·Long-term safety associations versus randomized data
• ·Clopidogrel and PPI interaction
• ·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