Gastroesophageal reflux disease (GERD) is a common condition with a significant economic impact. Many patients experience persistent symptoms despite proton pump inhibitor (PPI) therapy, which is often mislabeled as refractory GERD. The diagnosis of refractory GERD involves distinguishing between unproven and proven GERD, and identifying objective evidence of pathologic reflux. Refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, while proven refractory GERD requires personalized management, including non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management are crucial to prevent long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup, differentiates between unproven and proven GERD, and provides a comprehensive overview of current treatment strategies for refractory GERD.Gastroesophageal reflux disease (GERD) is a common condition with a significant economic impact. Many patients experience persistent symptoms despite proton pump inhibitor (PPI) therapy, which is often mislabeled as refractory GERD. The diagnosis of refractory GERD involves distinguishing between unproven and proven GERD, and identifying objective evidence of pathologic reflux. Refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, while proven refractory GERD requires personalized management, including non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management are crucial to prevent long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup, differentiates between unproven and proven GERD, and provides a comprehensive overview of current treatment strategies for refractory GERD.