gastroesophageal reflux disease

The most common symptoms of GERD in adults are an acidic taste in the mouth, regurgitation, and heartburn.{{Cite journal |display-authors=3 |vauthors=Zajac P, Holbrook A, Super ME, Vogt M |date=March–April 2013 |title=An overview: Current clinical guidelines for the evaluation, diagnosis, treatment, and management of dyspepsia |journal=Osteopathic Family Physician |volume=5 |issue=2 |pages=79–85 |doi=10.1016/j.osfp.2012.10.005}} Less common symptoms include pain with swallowing/sore throat, increased salivation (also known as water brash), nausea,{{Cite journal |vauthors=Kahrilas PJ |year=2008 |title=Gastroesophageal Reflux Disease |journal=The New England Journal of Medicine |volume=359 |issue=16 |pages=1700–7 |doi=10.1056/NEJMcp0804684 |pmc=3058591 |pmid=18923172}} chest pain, coughing, and globus sensation.{{Cite journal |last1=Clarrett |first1=Danisa M. |last2=Hachem |first2=Christine |date=May 2018 |title=Gastroesophageal Reflux Disease (GERD) |journal=Missouri Medicine |volume=115 |issue=3 |pages=214–218 |issn=0026-6620 |pmc=6140167 |pmid=30228725}} The acid reflux can induce asthma attack symptoms like shortness of breath, cough, and wheezing in those with underlying asthma.

GERD sometimes causes injury to the esophagus. These injuries may include one or more of the following:

• Reflux esophagitis – inflammation of esophageal epithelium which can cause ulcers near the junction of the stomach and esophagus{{Cite web |title=Esophagitis |url=https://www.lecturio.com/concepts/esophagitis/ |url-status=live |archive-url=https://web.archive.org/web/20210722075247/https://www.lecturio.com/concepts/esophagitis/ |archive-date=22 July 2021 |access-date=22 July 2021 |website=The Lecturio Medical Concept Library}}
• Esophageal strictures – the persistent narrowing of the esophagus caused by reflux-induced inflammation
• Barrett's esophagus – intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus{{Cite journal |display-authors=3 |vauthors=Shaheen NJ, Falk GW, Iyer PG, Gerson LB |date=January 2016 |title=ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus |url=https://cdr.lib.unc.edu/downloads/zc77sw61g |url-status=live |journal=Am. J. Gastroenterol. |volume=111 |issue=1 |pages=30–50; quiz 51 |doi=10.1038/ajg.2015.322 |pmc=10245082 |pmid=26526079 |s2cid=2274838 |archive-url=https://web.archive.org/web/20201107061040/https://cdr.lib.unc.edu/downloads/zc77sw61g |archive-date=7 November 2020 |access-date=7 October 2021 |doi-access=free}}
• Esophageal adenocarcinoma – a form of cancer

GERD sometimes causes injury of the larynx (LPR).{{Cite journal |vauthors=Lechien JR, Saussez S, Karkos PD |date=December 2018 |title=Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018 |journal=Curr Opin Otolaryngol Head Neck Surg |volume=26 |issue=6 |pages=392–402 |doi=10.1097/MOO.0000000000000486 |pmid=30234664 |s2cid=52307468}}{{Cite journal |display-authors=3 |vauthors=Lechien JR, Bobin F, Muls V, Eisendrath P, Horoi M, Thill MP, Dequanter D, Durdurez JP, Rodriguez A, Saussez S |date=December 2019 |title=Gastroesophageal reflux in laryngopharyngeal reflux patients: Clinical features and therapeutic response |journal=Laryngoscope |volume=130 |issue=8 |pages=E479–E489 |doi=10.1002/lary.28482 |pmid=31876296 |s2cid=209482485}} Other complications can include aspiration pneumonia.{{Cite journal |last1=Fass |first1=R |last2=Achem |first2=SR |last3=Harding |first3=S |last4=Mittal |first4=RK |last5=Quigley |first5=E |date=December 2004 |title=Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease and the role of night-time gastro-oesophageal reflux. |journal=Alimentary Pharmacology & Therapeutics |volume=20 |issue=Suppl 9 |pages=26–38 |doi=10.1111/j.1365-2036.2004.02253.x |pmid=15527462 |s2cid=23673597 |doi-access=free |s2cid-access=free}}

GERD may be difficult to detect in infants and children since they cannot describe what they are feeling and indicators must be observed. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems, such as wheezing. Inconsolable crying, refusing food, crying for food and then pulling off the bottle or breast only to cry for it again, failure to gain adequate weight, bad breath, and burping are also common. Children may have one symptom or many; no single symptom is universal in all children with GERD.{{cn|date=March 2025}}

Of the estimated 4 million babies born in the US each year, up to 35% of them may have difficulties with reflux in the first few months of their lives, known as 'spitting up'.{{Cite web |title=Spitting Up in Babies |url=http://familydoctor.org/online/famdocen/home/children/parents/infants/218.html |url-status=dead |archive-url=https://web.archive.org/web/20081008035333/http://www.familydoctor.org/online/famdocen/home/children/parents/infants/218.html |archive-date=8 October 2008 |publisher=familydoctor.org}} About 90% of infants will outgrow their reflux by their first birthday.{{Cite book |last1=Maqbool |first1=Asim |title=Nelson Textbook of Pediatrics |last2=Liacouras |first2=Chris A. |date=2020 |publisher=Elsevier |isbn=978-0-323-52950-1 |edition=21st |location=Philadelphia, PA |chapter=Normal Digestive Tract Phenomena}}

File:GERD 1.png

File:GERD 2.png

Acid reflux into the mouth can cause breakdown of the enamel, especially on the inside surface of the teeth. A dry mouth, acid or burning sensation in the mouth, bad breath and redness of the palate may occur.{{Cite journal |last1=Romano |first1=Claudio |last2=Cardile |first2=Sabrina |date=11 August 2014 |title=Gastroesophageal reflux disease and oral manifestations |journal=Italian Journal of Pediatrics |volume=40 |issue=Suppl 1 |pages=A73 |doi=10.1186/1824-7288-40-S1-A73 |pmc=4132436 |doi-access=free}} Less common symptoms of GERD include difficulty in swallowing, water brash, chronic cough, hoarse voice, nausea and vomiting.

Signs of enamel erosion are the appearance of a smooth, silky-glazed, sometimes dull, enamel surface with the absence of perikymata, together with intact enamel along the gum margin.{{Cite journal |vauthors=Lussi A, Jaeggi T |date=March 2008 |title=Erosion--diagnosis and risk factors |journal=Clinical Oral Investigations |volume=12 |issue=Suppl 1 |pages=S5–13 |doi=10.1007/s00784-007-0179-z |pmc=2238777 |pmid=18228059}} It will be evident in people with restorations as tooth structure typically dissolves much faster than the restorative material, causing it to seem as if it "stands above" the surrounding tooth structure.{{Cite journal |vauthors=Donovan T |year=2009 |title=Dental erosion |journal=Journal of Esthetic and Restorative Dentistry |volume=21 |issue=6 |pages=359–364 |doi=10.1111/j.1708-8240.2009.00291.x |pmid=20002921}}

{{Main|Barrett's esophagus}}

GERD may lead to Barrett's esophagus, a type of intestinal metaplasia, which is in turn a precursor condition for esophageal cancer. The risk of progression from Barrett's to dysplasia is uncertain, but is estimated at 20% of cases.[http://www.gerd-library.com/dysplasia-and-barretts-esophagus/Dysplasia and Barrett's Esophagus] {{Webarchive|url=https://web.archive.org/web/20150419032727/http://www.gerd-library.com/dysplasia-and-barretts-esophagus/Dysplasia |date=19 April 2015 }}. Retrieved on 1 February 2009. Due to the risk of chronic heartburn progressing to Barrett's, EGD every five years is recommended for people with chronic heartburn, or who take drugs for chronic GERD.{{Cite web |date=June 2009 |title=Patient information: Barrett's esophagus (Beyond the Basics) |url=http://www.uptodate.com/contents/barretts-esophagus-beyond-the-basics |url-status=live |archive-url=https://web.archive.org/web/20170909005636/http://www.uptodate.com/contents/barretts-esophagus-beyond-the-basics |archive-date=9 September 2017}}

File:GERD.png

A small amount of acid reflux is typical even in healthy people (as with infrequent and minor heartburn), but gastroesophageal reflux becomes gastroesophageal reflux disease when signs and symptoms develop into a recurrent problem. Frequent acid reflux is due to poor closure of the lower esophageal sphincter, which is at the junction between the stomach and the esophagus.

Factors that can contribute to GERD:

• Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.{{Cite journal |vauthors=Sontag SJ |year=1999 |title=Defining GERD |journal=Yale J Biol Med |volume=72 |issue=2–3 |pages=69–80 |pmc=2579007 |pmid=10780568}}{{Cite journal |display-authors=3 |vauthors=Piesman M, Hwang I, Maydonovitch C, Wong RK |date=October 2007 |title=Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter? |url=https://zenodo.org/record/1230696 |journal=American Journal of Gastroenterology |volume=102 |issue=10 |pages=2128–34 |doi=10.1111/j.1572-0241.2007.01348.x |pmid=17573791 |s2cid=11965042}}
• Obesity: increasing body mass index is associated with more severe GERD.{{Cite journal |display-authors=3 |vauthors=Ayazi S, Crookes PF, Peyre CG, Hagen JA, Leers JM, Tang AL, Ungnapatanin N, DeMeester SR, Lipham JC, DeMeester, TR |date=September 2007 |title=Objective documentation of the link between gastroesophageal reflux disease and obesity |journal=American Journal of Gastroenterology |volume=102 |pages=S138–S9 |doi=10.14309/00000434-200709002-00059}} In a large series of 2,000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index.{{Cite journal |display-authors=3 |vauthors=Ayazi S, Hagen JA, Chan LS, DeMeester SR, Lin MW, Ayazi A, Leers JM, Oezcelik A, Banki F, Lipham JC, DeMeester TR, Crookes PF |date=August 2009 |title=Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms |journal=J. Gastrointest. Surg. |volume=13 |issue=8 |pages=1440–7 |doi=10.1007/s11605-009-0930-7 |pmc=2710497 |pmid=19475461}}
• GERD can be a symptom of mast cell activation syndrome (MCAS).{{Cite journal |vauthors=Afrin LB, Butterfield JH, Raithel M, Molderings GJ |date=2016 |title=Often seen, rarely recognized: mast cell activation disease--a guide to diagnosis and therapeutic options |journal=The American Journal of the Medical Science |volume=48 |issue=3 |pages=190–201 |doi-access=free |doi=10.3109/07853890.2016.1161231 |pmid=27012973}}{{Cite journal |vauthors=Özdemir Ö, Kasımoğlu G, Bak A et al. |date=2024-06-09 |title=Mast cell activation syndrome: An up-to-date review of literature |journal=World J Clin Pediatr |volume=13 |issue=2 |doi-access=free |doi=10.5409/wjcp.v13.i2.92813 |pmc=11212760 |pmid=38948000}}

Factors that have been linked with GERD, but not conclusively:

• Obstructive sleep apnea{{Cite journal |display-authors=3 |vauthors=Morse CA, Quan SF, Mays MZ, Green C, Stephen G, Fass R |year=2004 |title=Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease? |journal=Clin. Gastroenterol. Hepatol. |volume=2 |issue=9 |pages=761–8 |doi=10.1016/S1542-3565(04)00347-7 |pmid=15354276 |doi-access=free}}{{Cite journal |vauthors=Kasasbeh A, Kasasbeh E, Krishnaswamy G |year=2007 |title=Potential mechanisms connecting asthma, esophageal reflux, and obesity/sleep apnea complex—a hypothetical review |journal=Sleep Med Rev |volume=11 |issue=1 |pages=47–58 |doi=10.1016/j.smrv.2006.05.001 |pmid=17198758}}
• Gallstones, which can impede the flow of bile into the duodenum, which can affect the ability to neutralize gastric acid{{Citation |last1=Tanaja |first1=Jasmin |title=Cholelithiasis |date=2022 |work=StatPearls |url=http://www.ncbi.nlm.nih.gov/books/NBK470440/ |access-date=30 October 2022 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29262107 |last2=Lopez |first2=Richard A. |last3=Meer |first3=Jehangir M.}}

In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pylori infection.{{Cite journal |vauthors=O'Connor HJ |date=Feb 1999 |title=Helicobacter pylori and gastro-oesophageal reflux disease-clinical implications and management |journal=Aliment Pharmacol Ther |volume=13 |issue=2 |pages=117–27 |doi=10.1046/j.1365-2036.1999.00460.x |pmid=10102940 |s2cid=41988457}} The eradication of H. pylori can lead to an increase in acid secretion,{{Cite journal |display-authors=3 |vauthors=El-Omar EM, Oien K, El-Nujumi A, Gillen D, Wirz A, Dahill S, Williams C, Ardill JE, McColl KE |year=1997 |title=Helicobacter pylori infection and chronic gastric acid hyposecretion |journal=Gastroenterology |volume=113 |issue=1 |pages=15–24 |doi=10.1016/S0016-5085(97)70075-1 |pmid=9207257}} leading to the question of whether H. pylori-infected GERD patients are any different from non-infected GERD patients. A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.{{Cite journal |display-authors=3 |vauthors=Fallone CA, Barkun AN, Mayrand S, Wakil G, Friedman G, Szilagyi A, Wheeler C, Ross D |date=October 2004 |title=There is no difference in the disease severity of gastro-oesophageal reflux disease between patients infected and not infected with Helicobacter pylori |journal=Aliment Pharmacol Ther |volume=20 |issue=7 |pages=761–8 |doi=10.1111/j.1365-2036.2004.02171.x |pmid=15379836 |s2cid=922610 |doi-access=free}}

The etiology of GERD appears to include the reflux of bile from the stomach into the esophagus leading to the production of reactive oxygen species and oxidative stress and then inflammation and induction of DNA damage.{{cite journal |vauthors=Bernard JN, Chinnaiyan V, Almeda J, Catala-Valentin A, Andl CD |title=Lactobacillus sp. Facilitate the Repair of DNA Damage Caused by Bile-Induced Reactive Oxygen Species in Experimental Models of Gastroesophageal Reflux Disease |journal=Antioxidants (Basel) |volume=12 |issue=7 |date=June 2023 |page=1314 |pmid=37507854 |pmc=10376144 |doi=10.3390/antiox12071314 |doi-access=free |url=}} In experimental models of GERD it was found that Lactobacilli facilitate the repair of such DNA damage indicating that administration of these potentially probiotic bacteria may be useful in patients suffering with GERD for preventing progression to Barrett’s esophagus and esophageal adenocarcinoma.

File:Peptic stricture.png image of peptic stricture, or narrowing of the esophagus near the junction with the stomach: This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing.]]

The diagnosis of GERD is usually made when typical symptoms are present. Reflux can be present in people without symptoms and the diagnosis requires both symptoms or complications and reflux of stomach content.

Other investigations may include esophagogastroduodenoscopy (EGD). Barium swallow X-rays should not be used for diagnosis.{{Cite journal |vauthors=Katz PO, Gerson LB, Vela MF |date=March 2013 |title=Guidelines for the diagnosis and management of gastroesophageal reflux disease |journal=American Journal of Gastroenterology |volume=108 |issue=3 |pages=308–28 |doi=10.1038/ajg.2012.444 |pmid=23419381 |doi-access=free}} Esophageal manometry is not recommended for use in the diagnosis, being recommended only prior to surgery. Ambulatory esophageal pH monitoring may be useful in those who do not improve after PPIs and is not needed in those in whom Barrett's esophagus is seen. Investigation for H. pylori is not usually needed.

The current gold standard for diagnosis of GERD is esophageal pH monitoring. It is the most objective test to diagnose the reflux disease and allows monitoring GERD patients in their response to medical or surgical treatment. One practice for diagnosis of GERD is a short-term treatment with proton-pump inhibitors, with improvement in symptoms suggesting a positive diagnosis. Short-term treatment with proton-pump inhibitors may help predict abnormal 24-hour pH monitoring results among patients with symptoms suggestive of GERD.{{Cite journal |vauthors=Numans ME, Lau J, de Wit NJ, Bonis PA |date=April 2004 |title=Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics |journal=Annals of Internal Medicine |volume=140 |issue=7 |pages=518–27 |doi=10.7326/0003-4819-140-7-200404060-00011 |pmid=15068979 |s2cid=53088422}}

Endoscopy, the examination of the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment. It is recommended when people either do not respond well to treatment or have alarm symptoms, including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett's esophagus.{{Citation |title=Patient information: Barrett's esophagus |url=http://www.uptodate.com/contents/barretts-esophagus-beyond-the-basics |archive-url=https://web.archive.org/web/20170909005636/http://www.uptodate.com/contents/barretts-esophagus-beyond-the-basics |archive-date=9 September 2017 |url-status=live}}

Biopsies performed during gastroscopy may show:

• Edema and basal hyperplasia (nonspecific inflammatory changes)
• Lymphocytic inflammation (nonspecific)
• Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
• Eosinophilic inflammation (usually due to reflux): The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (EE) if eosinophils are present in high enough numbers. Less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of GERD, is more consistent with GERD than EE.Mills, S (ed.) 2009.Sternberg's Diagnostic Pathology. 5th Edition. {{ISBN|978-0-7817-7942-5}}
• Goblet cell intestinal metaplasia or Barrett's esophagus
• Elongation of the papillae
• Thinning of the squamous cell layer
• Dysplasia
• Carcinoma

Reflux changes that are not erosive in nature lead to "nonerosive reflux disease".

Severity may be documented with the Johnson-DeMeester's scoring system:{{Cite web |last=Michael F. Vaezi, MD PhD MSc |title=Testing for refractory gastroesophageal reflux disease |url=https://www.asge.org/docs/default-source/education/leading-edge/9b4a3b9b-dca7-4988-8413-b43c5c403aa3.pdf |url-status=live |archive-url=https://web.archive.org/web/20180820234907/https://www.asge.org/docs/default-source/education/leading-edge/9b4a3b9b-dca7-4988-8413-b43c5c403aa3.pdf |archive-date=20 August 2018 |access-date=20 August 2018}}

0 – None

1 – Minimal – occasional episodes

2 – Moderate – medical therapy visits

3 – Severe – interference with daily activities

Other causes of chest pain such as heart disease should be ruled out before making the diagnosis. Another kind of acid reflux, which causes respiratory and laryngeal signs and symptoms, is called laryngopharyngeal reflux (LPR) or extraesophageal reflux disease (EERD). Unlike GERD, LPR rarely produces heartburn, and is sometimes called silent reflux.{{Cite web |last=Stuart |first=Annie |title=Laryngopharyngeal Reflux (Silent Reflux): Causes, Treatment, Diet, and More |url=https://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux |access-date=30 October 2022 |website=WebMD |language=en}} Differential diagnosis of GERD can also include dyspepsia, peptic ulcer disease, esophageal and gastric cancer, and food allergies.{{Cite journal |last1=Kellerman |first1=Rick |last2=Kintanar |first2=Thomas |date=December 2017 |title=Gastroesophageal Reflux Disease |journal=Primary Care |volume=44 |issue=4 |pages=561–573 |doi=10.1016/j.pop.2017.07.001 |issn=1558-299X |pmid=29132520}}

The treatments for GERD may include food choices, lifestyle changes, medications, and possibly surgery. Initial treatment is frequently with a proton-pump inhibitor such as omeprazole. In some cases, a person with GERD symptoms can manage them by taking over-the-counter drugs.{{Cite report |url=http://article.images.consumerreports.org/prod/content/dam/cro/news_articles/health/PDFs/Heartburn_fullreport.pdf |title=Using the Proton Pump Inhibitors to Treat Heartburn and Stomach Acid Reflux |year=2013 |publisher=Consumer Reports Best Buy Drugs |access-date=21 February 2020 |archive-url=https://web.archive.org/web/20200222023450/https://article.images.consumerreports.org/prod/content/dam/cro/news_articles/health/PDFs/Heartburn_fullreport.pdf |archive-date=22 February 2020 |url-status=live}}

• {{lay source |template=cite magazine |title=Choosing a PPI to Treat Heartburn, Acid Reflux & GERD |magazine=Consumer Reports |url=http://article.images.consumerreports.org/prod/content/dam/cro/news_articles/health/PDFs/Heartburn_2pagesummary.pdf}} This is often safer and less expensive than taking prescription drugs. Some guidelines recommend trying to treat symptoms with an H₂ antagonist before using a proton-pump inhibitor because of cost and safety concerns.

Medical nutrition therapy plays an essential role in managing the symptoms of the disease by preventing reflux, preventing pain and irritation, and decreasing gastric secretions.

Some foods such as chocolate, mint, high-fat food, and alcohol have been shown to relax the lower esophageal sphincter, increasing the risk of reflux. Weight loss is recommended for the overweight or obese, as well as avoidance of bedtime snacks or lying down immediately after meals (meals should occur at least 2–3 hours before bedtime), elevation of the head of the bed on 6-inch blocks, avoidance of smoking, and avoidance of tight clothing that increases pressure in the stomach. It may be beneficial to avoid spices, citrus juices, tomatoes and soft drinks, and to consume small frequent meals and drink liquids between meals.{{Cite journal |vauthors=Kaltenbach T, Crockett S, Gerson LB |year=2006 |title=Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach |journal=Arch. Intern. Med. |volume=166 |issue=9 |pages=965–71 |doi=10.1001/archinte.166.9.965 |pmid=16682569 |doi-access=free}} Some evidence suggests that reduced sugar intake and increased fiber intake can help.{{Cite journal |vauthors=Newberry C, Lynch K |date=20 July 2017 |title=Can We Use Diet to Effectively Treat Esophageal Disease? A Review of the Current Literature |journal=Current Gastroenterology Reports |volume=19 |issue=8 |page=38 |doi=10.1007/s11894-017-0578-5 |pmid=28730507 |s2cid=39516312}} Although moderate exercise may improve symptoms in people with GERD, vigorous exercise may worsen them.{{Cite journal |vauthors=Festi D, Scaioli E, Baldi F, Vestito A, Pasqui F, Di Biase AR, Colecchia A |date=14 April 2009 |title=Body weight, lifestyle, dietary habits and gastroesophageal reflux disease |journal=World Journal of Gastroenterology |volume=15 |issue=14 |pages=1690–701 |doi=10.3748/wjg.15.1690 |pmc=2668774 |pmid=19360912 |doi-access=free}} Breathing exercises may relieve GERD symptoms.{{Cite journal |last1=Qiu |first1=K |last2=Wang |first2=J |last3=Chen |first3=B |last4=Wang |first4=H |last5=Ma |first5=C |date=March 2020 |title=The effect of breathing exercises on patients with GERD: a meta-analysis. |journal=Annals of Palliative Medicine |volume=9 |issue=2 |pages=405–413 |doi=10.21037/apm.2020.02.35 |pmid=32233626 |doi-access=free}}

{{main|Drugs for acid-related disorders}}

The primary medications used for GERD are proton-pump inhibitors, H₂ receptor blockers and antacids with or without alginic acid. The use of acid suppression therapy is a common response to GERD symptoms and many people get more of this kind of treatment than their case merits.{{Cite journal |display-authors=3 |vauthors=Gupta R, Marshall J, Munoz JC, Kottoor R, Jamal MM, Vega KJ |year=2013 |title=Decreased acid suppression therapy overuse after education and medication reconciliation |journal=International Journal of Clinical Practice |volume=67 |issue=1 |pages=60–65 |doi=10.1111/ijcp.12046 |pmid=23241049 |s2cid=37158104 |doi-access=free}}{{Cite journal |vauthors=Nardino RJ, Vender RJ, Herbert PN |date=November 2000 |title=Overuse of acid-suppressive therapy in hospitalized patients |journal=American Journal of Gastroenterology |volume=95 |issue=11 |pages=3118–22 |doi=10.1016/s0002-9270(00)02052-9 |pmid=11095327}}{{Cite journal |vauthors=Heidelbaugh JJ, Kim AH, Chang R, Walker PC |year=2012 |title=Overutilization of proton-pump inhibitors: What the clinician needs to know |journal=Therapeutic Advances in Gastroenterology |volume=5 |issue=4 |pages=219–232 |doi=10.1177/1756283X12437358 |pmc=3388523 |pmid=22778788}}{{Cite journal |vauthors=Forgacs I, Loganayagam A |year=2008 |title=Overprescribing proton pump inhibitors |journal=BMJ |volume=336 |issue=7634 |pages=2–3 |doi=10.1136/bmj.39406.449456.BE |pmc=2174763 |pmid=18174564}}{{Cite journal |vauthors=McKay AB, Wall D |year=2008 |title=Overprescribing PPIs: An old problem |journal=BMJ |volume=336 |issue=7636 |pages=109.1–109 |doi=10.1136/bmj.39458.462338.3A |pmc=2206261 |pmid=18202040}} The overuse of acid suppression is a problem because of the side effects and costs.

Proton-pump inhibitors (PPIs), such as omeprazole, are the most effective, followed by H₂ receptor blockers, such as ranitidine. If a once-daily PPI is only partially effective they may be used twice a day. They should be taken one half to one hour before a meal. There is no significant difference between PPIs. When these medications are used long-term, the lowest effective dose should be taken.{{Cite journal |display-authors=3 |vauthors=Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM, Johnson SP, Allen J, Brill JV |date=October 2008 |title=American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease |journal=Gastroenterology |volume=135 |issue=4 |pages=1383–91, 1391.e1–5 |doi=10.1053/j.gastro.2008.08.045 |pmid=18789939 |doi-access=free}}

• {{lay source |template=cite web |title=American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease |website=National Guideline Clearinghouse |url=http://www.guideline.gov/content.aspx?id=13315 |archive-url=https://web.archive.org/web/20100817113825/http://www.guideline.gov/content.aspx?id=13315 |archive-date=17 August 2010}} They may also be taken only when symptoms occur in those with frequent problems. H₂ receptor blockers lead to roughly a 40% improvement.{{Cite journal |vauthors=Tran T, Lowry AM, El-Serag HB |year=2007 |title=Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs |journal=Aliment Pharmacol Ther |volume=25 |issue=2 |pages=143–53 |doi=10.1111/j.1365-2036.2006.03135.x |pmid=17229239 |s2cid=24358990 |doi-access=free}}

The evidence for antacids is weaker with a benefit of about 10% (NNT=13) while a combination of an antacid and alginic acid (such as Gaviscon) may improve symptoms by 60% (NNT=4). Metoclopramide (a prokinetic) is not recommended either alone or in combination with other treatments due to concerns around adverse effects. The benefit of the prokinetic mosapride is modest.

Sucralfate has similar effectiveness to H₂ receptor blockers; however, sucralfate needs to be taken multiple times a day, thus limiting its use. Baclofen, an agonist of the GABA_B receptor, while effective, has similar issues of needing frequent dosing in addition to greater adverse effects compared to other medications.

The standard surgical treatment for severe GERD is the Nissen fundoplication. In this procedure, the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.{{Cite journal |display-authors=3 |vauthors=Abbas AE, Deschamps C, Cassivi SD, Allen MS, Nichols FC, Miller DL, Pairolero PC |year=2004 |title=The role of laparoscopic fundoplication in Barrett's esophagus |journal=Annals of Thoracic Surgery |volume=77 |issue=2 |pages=393–6 |doi=10.1016/S0003-4975(03)01352-3 |pmid=14759403 |doi-access=free}} It is recommended only for those who do not improve with PPIs. Quality of life is improved in the short term compared to medical therapy, but there is uncertainty in the benefits of surgery versus long-term medical management with proton pump inhibitors.{{Cite journal |vauthors=Garg SK, Gurusamy KS |date=November 2015 |title=Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults |journal=Cochrane Database of Systematic Reviews |volume=2015 |issue=11 |pages=CD003243 |doi=10.1002/14651858.CD003243.pub3 |pmc=8278567 |pmid=26544951}} When comparing different fundoplication techniques, partial posterior fundoplication surgery is more effective than partial anterior fundoplication surgery,{{Cite journal |display-authors=3 |vauthors=Kurian AA, Bhayani N, Sharata A, Reavis K, Dunst CM, Swanström LL |date=January 2013 |title=Partial anterior vs partial posterior fundoplication following transabdominal esophagocardiomyotomy for achalasia of the esophagus: meta-regression of objective postoperative gastroesophageal reflux and dysphagia |journal=JAMA Surg |volume=148 |issue=1 |pages=85–90 |doi=10.1001/jamasurgery.2013.409 |pmid=23324843 |s2cid=9136476}} and partial fundoplication has better outcomes than total fundoplication.{{Cite journal |display-authors=3 |vauthors=Ramos RF, Lustosa SA, Almeida CA, Silva CP, Matos D |date=October–December 2011 |title=Surgical treatment of gastroesophageal reflux disease: total or partial fundoplication? systematic review and meta-analysis |journal=Arquivos de Gastroenterologia |volume=48 |issue=4 |pages=252–60 |doi=10.1590/s0004-28032011000400007 |pmid=22147130 |doi-access=free}}

Esophagogastric dissociation is an alternative procedure that is sometimes used to treat neurologically impaired children with GERD.{{Cite journal |display-authors=3 |vauthors=Gatti C, di Abriola GF, Villa M, De Angelis P, Laviani R, La Sala E, Dall'Oglio L |date=May 2001 |title=Esophagogastric dissociation versus fundoplication: Which is best for severely neurologically impaired children? |journal=Journal of Pediatric Surgery |volume=36 |issue=5 |pages=677–680 |doi=10.1053/jpsu.2001.22935 |pmid=11329564 |hdl-access=free |hdl=2108/311079}}{{Cite journal |display-authors=3 |vauthors=Morabito A, Lall A, Lo Piccolo R, McCarthy H, Kauffmann L, Ahmed S, Bianchi A |date=May 2006 |title=Total esophagogastric dissociation: 10 years' review |journal=Journal of Pediatric Surgery |volume=41 |issue=5 |pages=919–922 |doi=10.1016/j.jpedsurg.2006.01.013 |pmid=16677883}} Preliminary studies have shown it may have a lower failure rate{{Cite journal |display-authors=3 |vauthors=Goyal A, Khalil B, Choo K, Mohammed K, Jones M |date=June 2005 |title=Esophagogastric dissociation in the neurologically impaired: an alternative to fundoplication? |journal=Journal of Pediatric Surgery |volume=40 |issue=6 |pages=915–919 |doi=10.1016/j.jpedsurg.2005.03.004 |pmid=15991170}} and a lower incidence of recurrent reflux.

In 2012 the U.S. Food and Drug Administration (FDA) approved a device called the LINX, which consists of a series of metal beads with magnetic cores that are placed surgically around the lower esophageal sphincter, for those with severe symptoms that do not respond to other treatments. Improvement of GERD symptoms is similar to those of the Nissen fundoplication, although there is no data regarding long-term effects. Compared to Nissen fundoplication procedures, the procedure has shown a reduction in complications such as gas bloat syndrome that commonly occur.{{Cite journal |vauthors=Badillo R, Francis D |date=2014 |title=Diagnosis and treatment of gastroesophageal reflux disease |journal=World Journal of Gastrointestinal Pharmacology and Therapeutics |volume=5 |issue=3 |pages=105–12 |doi=10.4292/wjgpt.v5.i3.105 |doi-broken-date=19 April 2025 |pmc=4133436 |pmid=25133039 |doi-access=free}} Adverse responses include difficulty swallowing, chest pain, vomiting, and nausea. Contraindications that would advise against use of the device are patients who are or may be allergic to titanium, stainless steel, nickel, or ferrous iron materials. A warning advises that the device should not be used by patients who could be exposed to, or undergo, magnetic resonance imaging (MRI) because of serious injury to the patient and damage to the device.[https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm300790.htm Medical Device Approvals: LINX Reflux Management System - P100049] {{webarchive|url=https://web.archive.org/web/20131110133356/https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm300790.htm |date=10 November 2013 }}, U.S. Food and Drug Administration, U.S. Department of Health and Human Services, Update of 17 January 2014

Some patients who are at an increased surgical risk or do not tolerate PPIs{{Cite journal |vauthors=Testoni, S, Hassan, C, Mazzoleni, G, Antonelli, G, Fanti, L, Passaretti, S, Correale, L, Cavestro, G, Testoni, P |year=2021 |title=Long-term outcomes of transoral incisionless fundoplication for gastro-esophageal reflux disease: systematic-review and meta-analysis |journal=Endoscopy International Open |volume=9(2) |issue=C2 |pages=E239–E246 |doi=10.1055/a-1322-2209 |pmc=7857958 |pmid=33553587}} may qualify for a more recently developed incisionless procedure known as a TIF transoral incisionless fundoplication.{{Cite journal |vauthors=Jain D, Singhal S |date=March 2016 |title=Transoral Incisionless Fundoplication for Refractory Gastroesophageal Reflux Disease: Where Do We Stand? |journal=Clinical Endoscopy |volume=49 |issue=2 |pages=147–56 |doi=10.5946/ce.2015.044 |pmc=4821522 |pmid=26878326}} Benefits of this procedure may last for up to six years.{{Cite journal |vauthors=Hopkins J, Switzer NJ, Karmali S |date=25 August 2015 |title=Update on novel endoscopic therapies to treat gastroesophageal reflux disease: A review. |journal=World Journal of Gastrointestinal Endoscopy |volume=7 |issue=11 |pages=1039–44 |doi=10.4253/wjge.v7.i11.1039 |pmc=4549661 |pmid=26322157 |doi-access=free}}

GERD is a common condition that develops during pregnancy, but usually resolves after delivery.{{Cite journal |last1=Body |first1=Cameron |last2=Christie |first2=Jennifer A. |date=June 2016 |title=Gastrointestinal Diseases in Pregnancy: Nausea, Vomiting, Hyperemesis Gravidarum, Gastroesophageal Reflux Disease, Constipation, and Diarrhea |journal=Gastroenterology Clinics of North America |volume=45 |issue=2 |pages=267–283 |doi=10.1016/j.gtc.2016.02.005 |issn=1558-1942 |pmid=27261898}} The severity of symptoms tend to increase throughout the pregnancy. In pregnancy, dietary modifications and lifestyle changes may be attempted, but often have little effect. Some lifestyle changes that can be implemented are elevating the head of the bed, eating small portions of food at regularly scheduled intervals, reduce fluid intake with a meal, avoid eating three hours before bedtime, and refrain from lying down after eating. Calcium-based antacids are recommended if these changes are not effective; aluminum- and magnesium hydroxide-based antacids are also safe. Antacids that contain sodium bicarbonate or magnesium trisilicate should be avoided in pregnancy. Sucralfate has been studied in pregnancy and proven to be safe as is ranitidine{{Cite journal |vauthors=Mahadevan U, Kane S |date=July 2006 |title=American gastroenterological association institute medical position statement on the use of gastrointestinal medications in pregnancy |journal=Gastroenterology |volume=131 |issue=1 |pages=278–82 |doi=10.1053/j.gastro.2006.04.048 |pmid=16831610 |doi-access=free}} and PPIs.{{Cite journal |vauthors=Katz PO, Gerson LB, Vela MF |date=March 2013 |title=Guidelines for the diagnosis and management of gastroesophageal reflux disease |journal=American Journal of Gastroenterology |volume=108 |issue=3 |pages=308–28 |doi=10.1038/ajg.2012.444 |pmid=23419381 |doi-access=free}}

Babies may see relief with smaller, more frequent feedings, more frequent burping during feedings, holding the baby in an upright position 30 minutes after feeding, keeping the baby's head elevated while laying on the back, removing milk and soy from the mother's diet or feeding the baby milk protein-free formula.{{Cite web |title=Infant acid reflux - Diagnosis and treatment - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/diagnosis-treatment/drc-20351412 |url-status=live |archive-url=https://web.archive.org/web/20200514231419/https://www.mayoclinic.org/diseases-conditions/infant-acid-reflux/diagnosis-treatment/drc-20351412 |archive-date=14 May 2020 |access-date=28 September 2018 |website=www.mayoclinic.org}} They may also be treated with medicines such as ranitidine or proton pump inhibitors.{{Cite journal |vauthors=Tighe MP, Afzal NA, Bevan A, Beattie RM |year=2009 |title=Current pharmacological management of gastro-esophageal reflux in children: an evidence-based systematic review |journal=Paediatr Drugs |volume=11 |issue=3 |pages=185–202 |doi=10.2165/00148581-200911030-00004 |pmid=19445547 |s2cid=42736509}} Proton pump inhibitors, however, have not been found to be effective in this population and there is a lack of evidence for safety.{{Cite journal |display-authors=3 |vauthors=van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA |date=May 2011 |title=Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review |journal=Pediatrics |volume=127 |issue=5 |pages=925–35 |doi=10.1542/peds.2010-2719 |pmid=21464183 |s2cid=207164814}} The role of an occupational therapist with an infant with GERD includes positioning during and after feeding.{{Cite web |last=chantelpowellot |date=14 July 2014 |title=Helping Baby with Gastroesophageal Reflux Disorder (GERD) |url=https://powellpediatrictherapy.com/2014/07/14/helping-your-baby-with-gastroesophageal-reflux-disorder-gerd/ |url-status=live |archive-url=https://web.archive.org/web/20210504155114/https://powellpediatrictherapy.com/2014/07/14/helping-your-baby-with-gastroesophageal-reflux-disorder-gerd/ |archive-date=4 May 2021 |access-date=3 May 2021 |website=Occupational Therapy Services in North County San Diego |language=en}} One technique used is called the log-roll technique, which is practiced when changing an infant's clothing or diapers. Placing an infant on their back while having their legs lifted is not recommended since it causes the acid to flow back up the esophagus. Instead, the occupational therapist would suggest rolling the child on the side, keeping the shoulders and hips aligned to avoid acid rising up the baby's esophagus. Another technique used is feeding the baby on their side with an upright position instead of lying flat on their back. The final positioning technique used for infants is to keep them on their stomach or upright for 20 minutes after feeding.{{Cite journal |last=Elser |first=Heather E. |date=2012 |title=Positioning after feedings: what is the evidence to reduce feeding intolerances? |journal=Advances in Neonatal Care |volume=12 |issue=3 |pages=172–175 |doi=10.1097/ANC.0b013e318256b7c1 |issn=1536-0911 |pmid=22668689}}

In Western populations, GERD affects approximately 10% to 20% of the population and 0.4% newly develop the condition. For instance, an estimated 3.4 million to 6.8 million Canadians have GERD. The prevalence rate of GERD in developed nations is also tightly linked with age, with adults aged 60 to 70 being the most commonly affected.{{Cite journal |vauthors=Fedorak RN, Veldhuyzen van Zanten S, Bridges R |date=July 2010 |title=Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal reflux disease in Canada: Incidence, prevalence, and direct and indirect economic impact |journal=Canadian Journal of Gastroenterology |volume=24 |issue=7 |pages=431–4 |doi=10.1155/2010/296584 |pmc=2918483 |pmid=20652158 |doi-access=free}} In the United States 20% of people have symptoms in a given week and 7% every day. No data supports sex predominance with regard to GERD.{{Cite journal |last1=Kim |first1=Young Sun |last2=Kim |first2=Nayoung |last3=Kim |first3=Gwang Ha |date=30 October 2016 |title=Sex and Gender Differences in Gastroesophageal Reflux Disease |journal=Journal of Neurogastroenterology and Motility |language=en |volume=22 |issue=4 |pages=575–588 |doi=10.5056/jnm16138 |issn=2093-0879 |pmc=5056567 |pmid=27703114}}

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication. Vagotomy by itself tended to worsen contraction of the pyloric sphincter of the stomach, and delayed stomach emptying. Historically, vagotomy was combined with pyloroplasty or gastroenterostomy to counter this problem.{{Cite journal |last1=HINES |first1=JAMES R. |last2=GEURKINK |first2=ROBERT E. |last3=KORNMESSER |first3=THOMAS A. |last4=WIKHOLM |first4=LARRY |last5=DAVIS |first5=ROBERT P. |date=1975 |title=Vagotomy and Double Pyloroplasty for Peptic Ulcer |journal=Annals of Surgery |language=en |volume=181 |issue=1 |pages=40–46 |doi=10.1097/00000658-197501000-00010 |issn=0003-4932 |pmc=1343712 |pmid=1119866}}

A number of endoscopic devices have been tested to treat chronic heartburn.

• Endocinch puts stitches in the lower esophogeal sphincter (LES) to create small pleats to help strengthen the muscle. However, long-term results were disappointing, and the device is no longer sold by Bard.{{Cite journal |vauthors=Jafri SM, Arora G, Triadafilopoulos G |date=July 2009 |title=What is left of the endoscopic antireflux devices? |journal=Current Opinion in Gastroenterology |volume=25 |issue=4 |pages=352–7 |doi=10.1097/MOG.0b013e32832ad8b4 |pmid=19342950 |s2cid=5280924}}
• The Stretta procedure uses electrodes to apply radio-frequency energy to the LES. A 2015 systematic review and meta-analysis in response to the systematic review (no meta-analysis) conducted by SAGES did not support the claims that Stretta was an effective treatment for GERD.{{Cite journal |vauthors=Lipka S, Kumar A, Richter JE |date=June 2015 |title=No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. |journal=Clinical Gastroenterology and Hepatology |volume=13 |issue=6 |pages=1058–67.e1 |doi=10.1016/j.cgh.2014.10.013 |pmid=25459556}} A 2012 systematic review found that it improves GERD symptoms.{{Cite journal |vauthors=Perry KA, Banerjee A, Melvin WS |date=August 2012 |title=Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis. |journal=Surgical Laparoscopy, Endoscopy & Percutaneous Techniques |volume=22 |issue=4 |pages=283–8 |doi=10.1097/sle.0b013e3182582e92 |pmid=22874675 |s2cid=5813552}}
• NDO Surgical Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The company ceased operations in mid-2008, and the device is no longer on the market.{{cn|date=March 2025}}
• Transoral incisionless fundoplication, which uses a device called Esophyx, may be effective.{{Cite journal |vauthors=Testoni PA, Vailati C |date=August 2012 |title=Transoral incisionless fundoplication with EsophyX® for treatment of gastro-oesphageal reflux disease |journal=Digestive and Liver Disease |volume=44 |issue=8 |pages=631–5 |doi=10.1016/j.dld.2012.03.019 |pmid=22622203}}

• Acid perfusion test
• EndoStim Electrical Stimulation Therapy
• Esophageal motility disorder
• Esophageal motility study

{{reflist|colwidth=30em}}

• {{Cite journal |display-authors=3 |vauthors=Lichtenstein DR, Cash BD, Davila R, Baron TH, Adler DG, Anderson MA, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Qureshi WA, Rajan E, Shen B, Zuckerman MJ, Fanelli RD, VanGuilder T |date=August 2007 |title=Role of endoscopy in the management of GERD |url=https://www.asge.org/docs/default-source/education/practice_guidelines/doc-endoscopy_in_the_managment_of_gerd.pdf |journal=Gastrointestinal Endoscopy |volume=66 |issue=2 |pages=219–24 |doi=10.1016/j.gie.2007.05.027 |pmid=17643692}}
• {{lay source |template=cite web |title=Role of endoscopy in the management of GERD |website=National Guideline Clearinghouse |url=http://www.guideline.gov/content.aspx?id=12023 |archive-url=https://web.archive.org/web/20100928094032/https://www.guideline.gov/content.aspx?id=12023 |archive-date=28 September 2010}}
• {{Cite journal |vauthors=Hirano I, Richter JE |date=March 2007 |title=ACG practice guidelines: esophageal reflux testing |journal=American Journal of Gastroenterology |volume=102 |issue=3 |pages=668–85 |citeseerx=10.1.1.619.3818 |doi=10.1111/j.1572-0241.2006.00936.x |pmid=17335450 |s2cid=10854440}}
• {{Cite journal |vauthors=Katz PO, Gerson LB, Vela MF |date=March 2013 |title=Guidelines for the diagnosis and management of gastroesophageal reflux disease |journal=American Journal of Gastroenterology |volume=108 |issue=3 |pages=308–28 |doi=10.1038/ajg.2012.444 |pmid=23419381 |doi-access=free}}

{{Medical condition classification and resources

| DiseasesDB = 23596

| ICD10 = {{ICD10|K|21||k|20}}

| ICD9 = {{ICD9|530.81}}

| ICDO =

| OMIM = 109350

| MedlinePlus = 000265

| eMedicineSubj = med

| eMedicineTopic = 857

| eMedicine_mult = {{eMedicine2|ped|1177}} {{eMedicine2|radio|300}}

| MeshID = D005764

|ICD10CM={{ICD10CM|K21}}|ICD11={{ICD11|DA22}}}}

{{Digestive system diseases}}

{{Drugs for peptic ulcer and GORD}}

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Category:Medical conditions related to obesity

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Category:Gastrointestinal motility disorders