Thorough work-up of patients with PPI-refractory heartburn is important to find the minority of patients with true reflux-related symptoms who may benefit from surgery, a clinical trial suggests.

US researchers enrolled 366 people (median age 48.5 years, mostly male) presenting at veterans’ gastroenterology clinics with PPI-refractory heartburn.

A rigorous work-up found only 21% of the patients had true reflux that might respond to surgery, the authors reported in the NEJM.

These patients were randomised to three arms: laproscopic Nissen fundoplication, active medical treatment (20mg omeprazole twice daily plus 20mg baclofen three times a day with 100mg desipramine added at bedtime depending on symptoms), or control medical treatment (omeprazole alone).