What Actually Causes GERD and Acid Reflux? Why Long-Term PPI Use Often Makes It Worse — The clinical pattern that defines treatment-resistant GERD

A patient presents with heartburn, regurgitation, and chest discomfort after meals, often worsening when lying down. The symptoms have been present for months or years. A trial of over-the-counter antacids provided partial relief. The primary care physician prescribed a PPI. The reflux symptoms improved substantially. The patient has remained on the PPI for years, often a decade or longer. Over time, the dose has been increased, or a second daily dose was added, or the patient switched between different PPIs trying to find one that worked better. In the more recent years, new symptoms have appeared. Bloating after meals. Persistent fullness. Food sensitivities to items that were previously tolerated. Constipation or alternating bowel patterns. Fatigue. Brain fog. Occasional palpitations. The patient may have been told they have IBS, or SIBO, or functional dyspepsia, depending on which specialist they saw. The reflux symptoms have either persisted despite the medication or partially returned, prompting consideration of adding a histamine blocker (H2 antagonist) or trying a different PPI. The patient tries to come off the PPI. The reflux symptoms return within days, often worse than before treatment began. This is interpreted as confirmation that the medication is necessary. The patient resumes the PPI. The cycle continues. Some patients accept the lifelong medication. Others con