What is the next step for patients with stomach ulcers and Gastroesophageal Reflux Disease (GERD) who do not respond to Proton Pump Inhibitor (PPI) therapy?

Management of Stomach Ulcers and GERD When PPI Therapy Isn't Working

For patients with stomach ulcers and GERD who do not respond to PPI therapy, the next steps should include diagnostic testing with endoscopy and pH monitoring, followed by either increasing PPI dosing, adding adjunctive medications, or considering surgical interventions based on test results. 1, 2

Diagnostic Evaluation for PPI Non-Responders

Initial Assessment

• Verify PPI compliance and proper administration (30-60 minutes before meals)
• Rule out medication-related causes (NSAIDs, aspirin)
• Consider upper endoscopy to:
  • Assess for persistent erosive esophagitis
  • Evaluate for alternative diagnoses (eosinophilic esophagitis, pill esophagitis)
  • Measure hiatal hernia size
  • Check for Barrett's esophagus

Reflux Testing

• Prolonged wireless pH monitoring (preferably off PPI for 96 hours) to determine if:
  • No GERD: AET <4.0% on all days (consider discontinuing PPI)
  • Conclusive GERD: AET ≥6.0% on 2+ days (maintain PPI)
  • Borderline GERD: AET ≥4.0% but not meeting conclusive criteria 1, 2

Treatment Algorithm for PPI Non-Responders

Step 1: Optimize PPI Therapy

• Increase to twice daily dosing (not FDA approved but commonly used) 1
• Consider switching to a more effective PPI (esomeprazole 40mg twice daily for 8-12 weeks) 2
• Ensure proper timing (30-60 minutes before meals) 2

Step 2: Add Adjunctive Medications

• H2-receptor antagonists at bedtime for nighttime reflux 3
• Baclofen (5-20mg three times daily) to reduce transient lower esophageal sphincter relaxations 2, 4
• Alginate-containing antacids to help localize and displace postprandial acid pocket 2
• Prokinetic agents (metoclopramide, domperidone) if gastroparesis is suspected 2

Step 3: Based on Diagnostic Testing Results

For Confirmed GERD with Persistent Symptoms:

• Consider surgical or endoscopic anti-reflux procedures:
  • Laparoscopic fundoplication
  • Magnetic sphincter augmentation
  • Transoral incisionless fundoplication 1, 2

For Non-GERD Causes:

• For functional heartburn or visceral hypersensitivity:
  • Pain modulators (low-dose tricyclic antidepressants)
  • Cognitive behavioral therapy or gut-directed hypnotherapy 1, 3
• For upper esophageal sphincter dysfunction:
  • Consider UES compression device 1

Special Considerations

Severe GERD Phenotype

Patients with Los Angeles Grade C/D esophagitis, AET >12.0%, or DeMeester Score ≥50 may require:

• Continuous long-term PPI therapy
• Earlier consideration of anti-reflux procedures 1

Caution with Anti-Reflux Surgery

• Lack of response to PPI therapy predicts poor response to anti-reflux surgery 1
• Best candidates have:
  • Documented GERD (abnormal pH study)
  • Good symptom correlation with reflux events
  • Predominant regurgitation symptoms 3, 5

Lifestyle Modifications

• Weight management for overweight/obese patients
• Elevate head of bed 6-8 inches
• Avoid meals within 3 hours of bedtime
• Identify and avoid specific trigger foods
• Consider smaller, more frequent meals that are low in fat 2

Common Pitfalls to Avoid

1. Continuing ineffective PPI therapy without diagnostic testing
2. Referring for surgery without objective confirmation of GERD
3. Overlooking alternative diagnoses (eosinophilic esophagitis, achalasia, rumination)
4. Failing to assess for medication compliance and proper administration
5. Not considering functional disorders in patients with normal reflux testing 3, 5