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Step 4: Remove the needle from the bacteriostatic water vial and insert it into the Methylcobalamin 10,000 mcg vial of powder

Causes of Refractory Reflux Symptoms in Patients Receiving Proton Pump Inhibitor Therapy Incorrect initial diagnosis Nonreflux esophagitispill injury, skin diseases, eosinophilic esophagitis, infection Heart disease Chest wall pain Gastric pain Additional diagnoses Dyspepsia Delayed gastric emptying Gastritis Peptic ulcer disease Nonulcer dyspepsia Inadequate acid suppression Noncompliance Rapid metabolizers of proton pump inhibitors Dose timing Insufficient dose Zollinger-Ellison syndrome Nonacid reflux Adenocarcinoma in Barrett esophagus Postoperative reflux Partial gastrectomy Vertical-banded gastroplasty Esophageal dysmotility Spasm Achalasia Nutcracker esophagus Functional chest pain Hypersensitive esophagus Somatic features of depression Functional heartburn Free regurgitation Absence of lower esophageal sphincter tone Large hiatal hernia Achalasia Rumination rumination or gastroparesis) or functional conditions (eg, functional heartburn)

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