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Esophagus· Chapter 03

GERD and Refractory Reflux

The Lyon Consensus framework for proving reflux: when pH-impedance confirms it, when it doesn't, and what to do with refractory symptoms. PPI failure, vonoprazan and other PCABs, fundoplication candidacy, and the brain-gut diagnoses (NERD, reflux hypersensitivity, functional heartburn) that masquerade as treatment-resistant disease.

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34 MCQs3 podcast episodes
  • Audio chapter
    Attending-narrated, listen on the commute.
  • ABIM-format MCQs
    5-option vignettes with full wrong-answer teaching.
  • Study guide
    Tables, decision trees, primary sources.
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    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 candidate should approach the surgical question as a matching problem rather than as a default referral.

  • Section 3.6: Refractory GERD evaluation and management

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

Podcast episodes

  1. 01

    Mechanisms and Endoscopy

    This episode covers how reflux actually happens and how the endoscopy grades it. The single most useful idea to start with is that GERD is a failure of the barrier that keeps acid in the stomach, not a problem of making too much acid, and once you see it that way the whole chapter follows in order.

  2. 02

    Acid Suppression Drugs

    This episode covers the acid-suppressing drugs, and here the mechanism explains both the strength and, crucially, the timing that decides whether the drug even works.

  3. 03

    Refractory Lyon Surgery Functional

    This episode covers the patient whose reflux drug has failed: the framework that separates real reflux from an oversensitive esophagus, the antireflux surgery that's only appropriate once you've actually proven reflux, and the workup of persistent symptoms, where the answer is usually not reflux at all.