Gastroesophageal reflux disease (GERD) is a common condition with increasing global prevalence and significant economic burden. Persistent symptoms after proton pump inhibitor (PPI) therapy may be mislabeled as refractory GERD. Diagnosis of refractory GERD requires objective evidence of pathologic reflux, such as abnormal pH-impedance monitoring or erosive esophagitis on endoscopy. Differentiating between refractory symptoms (symptoms persisting despite optimized therapy) and refractory GERD (abnormal reflux metrics on monitoring) is crucial for appropriate management. Refractory GERD may result from esophageal hypersensitivity or functional heartburn, requiring personalized treatment with non-pharmacologic, pharmacologic, endoscopic, or surgical interventions. Proper diagnosis and management are essential to prevent long-term complications like strictures, Barrett's esophagus, and esophageal adenocarcinoma. Diagnostic evaluation includes upper endoscopy, pH-impedance monitoring, and high-resolution manometry. Treatment options include optimizing PPI therapy, using potassium competitive acid blockers, lifestyle modifications, and surgical interventions like antireflux surgery or magnetic sphincter augmentation. Management should be individualized based on patient-specific factors and clinical context.Gastroesophageal reflux disease (GERD) is a common condition with increasing global prevalence and significant economic burden. Persistent symptoms after proton pump inhibitor (PPI) therapy may be mislabeled as refractory GERD. Diagnosis of refractory GERD requires objective evidence of pathologic reflux, such as abnormal pH-impedance monitoring or erosive esophagitis on endoscopy. Differentiating between refractory symptoms (symptoms persisting despite optimized therapy) and refractory GERD (abnormal reflux metrics on monitoring) is crucial for appropriate management. Refractory GERD may result from esophageal hypersensitivity or functional heartburn, requiring personalized treatment with non-pharmacologic, pharmacologic, endoscopic, or surgical interventions. Proper diagnosis and management are essential to prevent long-term complications like strictures, Barrett's esophagus, and esophageal adenocarcinoma. Diagnostic evaluation includes upper endoscopy, pH-impedance monitoring, and high-resolution manometry. Treatment options include optimizing PPI therapy, using potassium competitive acid blockers, lifestyle modifications, and surgical interventions like antireflux surgery or magnetic sphincter augmentation. Management should be individualized based on patient-specific factors and clinical context.