After starting PPI therapy for GERD, which symptom pattern may persist due to nonacid reflux?

• A. Complete resolution of all symptoms
• B. Worsening acid reflux
• C. No reflux at all
• D. Nonacid reflux causing ongoing symptoms

Answer: (D)

The key idea is that acid suppression with a PPI doesn’t stop reflux itself; it only reduces how acidic the refluxate is. So even after starting therapy, reflux events can continue, but they may be nonacid. When the refluxate isn’t sufficiently acidic, acid-focused symptoms improve, but nonacid components (like bile or nonacid gastric contents) can still irritate the esophagus or airway and trigger ongoing symptoms such as regurgitation, cough, throat irritation, or hoarseness. That’s why ongoing symptoms despite PPI therapy are often due to nonacid reflux. To investigate, impedance-pH testing can detect reflux episodes regardless of pH, helping confirm nonacid reflux. Management may involve lifestyle changes, alginates, prokinetics if appropriate, or addressing airway/laryngeal symptoms tied to nonacid reflux.