GERD: Acid Reflux, Causes and Treatment

GERD: Acid Reflux, Causes and Treatment

Gastroesophageal reflux disease (GERD) — known as acid reflux disease — occurs when stomach contents, including acid and bile, reflux abnormally and persistently into the oesophagus, causing troublesome symptoms and/or mucosal damage. It is one of the most prevalent gastrointestinal conditions worldwide, affecting approximately 20% of adults in Western countries and up to 10–15% in East Asia — with prevalence rising rapidly in China alongside westernisation of diet and lifestyle.

GERD has a significant impact on quality of life — chronic heartburn and regurgitation disrupt sleep, restrict diet, and impair work performance. Left unmanaged, GERD can cause oesophageal mucosal injury (oesophagitis), oesophageal stricture, and — in a subset of patients — Barrett's oesophagus, a pre-malignant condition that can progress to oesophageal adenocarcinoma.

How Reflux Occurs

Under normal conditions, the lower oesophageal sphincter (LOS) — a zone of tonically contracted smooth muscle at the junction of the oesophagus and stomach — acts as a one-way valve, preventing gastric contents from entering the oesophagus. Swallowing causes coordinated LOS relaxation to allow food to pass. Transient LOS relaxations (TLOSRs) are a separate process that occurs independently of swallowing; they permit belching and can also allow reflux.

In GERD, the LOS is dysfunctional — either through:

1. Reduced LOS basal tone — allowing persistent upward reflux, particularly in supine position and with increased intra-abdominal pressure; associated with obesity, pregnancy, and certain medications
2. Excessive transient LOS relaxations (TLOSRs) — the most common mechanism in non-obese GERD; episodes of inappropriate LOS relaxation allow acid to reflux even with normal basal tone
3. Hiatal hernia — displacement of the gastro-oesophageal junction through the diaphragmatic hiatus into the chest; disrupts the anti-reflux barrier and is present in the majority of patients with severe oesophagitis

The oesophageal mucosa lacks the protective mucus layer and acid-buffering capacity of the stomach — repeated acid exposure causes inflammation, erosion, and eventually structural damage.

Risk Factors

Risk Factor	Mechanism
Obesity / central adiposity	Increased intra-abdominal pressure; higher frequency of TLOSRs; adipose-derived hormones alter LOS function
Hiatal hernia	Disrupts anatomical anti-reflux barrier
Pregnancy	Progesterone reduces LOS tone; uterus increases intra-abdominal pressure
Smoking	Reduces LOS tone; impairs oesophageal acid clearance
Dietary triggers	Fatty foods, chocolate, peppermint, alcohol, coffee, citrus — transiently relax LOS or delay gastric emptying
Large meals / late eating	Distension relaxes LOS; recumbency after meals promotes reflux
Medications	Calcium channel blockers, nitrates, anticholinergics, tricyclics, bisphosphonates — reduce LOS tone or directly irritate mucosa
Connective tissue disorders	Scleroderma — LOS atony and impaired oesophageal peristalsis

Symptoms

Typical Symptoms

Heartburn (pyrosis) — the cardinal symptom; a burning discomfort or pain rising from the epigastrium into the retrosternal area (behind the breastbone), often reaching the throat; typically worst after meals, when bending forward, and lying down; relieved (transiently) by antacids or sitting upright.

Regurgitation — effortless return of gastric contents (acid or food) into the mouth or throat without the muscle effort of vomiting; often associated with a sour or bitter taste; may cause waterbrash (sudden mouth filling with saliva as a vagal response to acid in the oesophagus).

Atypical / Extraoesophageal Symptoms

GERD can manifest without classic heartburn:

• Chronic cough — acid reflux triggering vagal reflex cough; most prominent when supine or after meals; often misdiagnosed and undertreated
• Laryngopharyngeal reflux (LPR) — acid reaching the pharynx and larynx; causes throat clearing, hoarseness, globus sensation (lump in throat), and chronic throat irritation
• Asthma exacerbation — acid-triggered bronchospasm; GERD is a common trigger in difficult-to-control asthma
• Non-cardiac chest pain — oesophageal spasm from acid exposure; mimics cardiac angina; must be distinguished by cardiac evaluation before attributing to GERD
• Dental erosion — chronic acid exposure to teeth during sleep-related reflux
• Sleep disturbance — nocturnal reflux frequently disrupts sleep quality

Alarm Symptoms Requiring Urgent Investigation

• Dysphagia (difficulty swallowing) — suggests peptic stricture, oesophageal cancer, or achalasia
• Odynophagia (painful swallowing)
• Unintentional weight loss
• Haematemesis or melaena (GI bleeding)
• Anaemia
• New or changing symptoms in an older adult — assessment considers age together with alarm features and other cancer risk factors; age alone is not a universal endoscopy rule

Diagnosis

Empirical PPI Trial

For typical heartburn and regurgitation without alarm symptoms, ACG recommends an 8-week once-daily PPI trial before a meal. Improvement supports the working diagnosis but does not prove GERD; persistent or recurrent symptoms may require further assessment.

Upper GI Endoscopy (Gastroscopy)

Endoscopy allows direct visualisation of the oesophageal mucosa and is used to:

• Diagnose and grade oesophagitis (Los Angeles Classification: grades A–D)
• Diagnose Barrett's oesophagus — metaplastic columnar mucosa replacing squamous oesophageal epithelium
• Exclude oesophageal cancer, peptic strictures, eosinophilic oesophagitis, and other causes of symptoms
• Obtain biopsies from Barrett's mucosa for dysplasia surveillance

Los Angeles Classification of Oesophagitis:

• Grade A: ≥1 mucosal break ≤5 mm, not extending between mucosal folds
• Grade B: ≥1 mucosal break >5 mm, not extending between mucosal folds
• Grade C: Mucosal breaks extending between folds but <75% of oesophageal circumference
• Grade D: Mucosal breaks ≥75% of oesophageal circumference

Endoscopy in GERD is normal (non-erosive reflux disease — NERD) in approximately 50–70% of patients, even with significant symptoms.

24-Hour pH Monitoring / pH-Impedance Study

A pH-only study measures acid exposure; combined pH-impedance also detects weakly acidic and non-acid reflux and can assess its relationship to symptoms. Catheter studies commonly record over 24 hours. The clinician chooses the test and whether it should be performed on or off acid-suppressing treatment. Uses include:

• Objective assessment before anti-reflux intervention when required
• Investigation of persistent symptoms despite treatment
• Distinguishing reflux-related symptoms from functional heartburn

Wireless Bravo pH capsule — a small capsule attached to the oesophageal wall via endoscopy; records pH for 48–96 hours without nasal catheter; well tolerated.

Oesophageal Manometry

High-resolution manometry maps oesophageal pressure along the entire length, characterising LOS tone, oesophageal peristalsis, and the presence of hiatal hernia. Essential before anti-reflux surgery to exclude achalasia and severe peristaltic dysfunction.

Treatment

Lifestyle Modifications

Effective for mild GERD and as adjuncts to medication:

• Weight management — weight loss can improve reflux symptoms in people who are overweight or have obesity; it is not a general instruction for people who are normal-weight or underweight
• Elevate head of bed (15–20 cm) or use a wedge pillow — reduces nocturnal reflux
• Avoid eating within 3 hours of bedtime
• Dietary triggers — identify and avoid personal triggers (fatty foods, alcohol, coffee, chocolate, citrus, peppermint)
• Smoking cessation
• Avoid tight clothing

Proton Pump Inhibitors (PPIs)

A mainstay of GERD pharmacotherapy, with selection and dosing based on symptoms and oesophageal findings:

Examples: omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole

Dosing: conventional PPIs are generally taken 30–60 minutes before a meal. Dose escalation depends on symptoms and findings; Barrett’s oesophagus alone does not automatically require twice-daily treatment. Follow the prescribed product and regimen.

PPIs heal oesophagitis in 80–90% of patients within 8 weeks. Symptom relief in 70–80% of those with NERD.

Long-term use: maintenance is generally needed for severe erosive oesophagitis (LA grade C/D); other patients should use the lowest effective regimen appropriate to their condition. Barrett’s oesophagus is usually managed with ongoing PPI therapy unless contraindicated, but extra cancer prevention from higher doses is uncertain. Discuss benefits and risks with the clinician; observational associations with adverse outcomes do not by themselves prove that PPIs caused them.

Potassium-competitive acid blockers (P-CABs): vonoprazan (approved in Japan, South Korea, China) — faster onset and longer acid suppression than PPIs; particularly effective for severe oesophagitis and H. pylori eradication.

H2-Receptor Antagonists

Famotidine, ranitidine (withdrawn due to NDMA contamination) — weaker acid suppression than PPIs; useful for on-demand/intermittent relief; rapid onset for breakthrough heartburn.

Alginate-based and Antacid Preparations

Gaviscon (alginate + antacid) — forms a raft above the gastric contents, mechanically reducing reflux episodes; effective for post-prandial and positional heartburn.

Anti-Reflux Surgery

For patients who prefer to discontinue lifelong medication, have significant regurgitation not controlled by PPIs (PPIs reduce acid but not the volume of reflux), or have large hiatal hernias causing mechanical symptoms:

Laparoscopic Nissen fundoplication — the most common anti-reflux operation. The fundus of the stomach is wrapped 360° around the lower oesophagus, reinforcing the LOS and reducing TLOSRs. Performed laparoscopically as a 1–2 night inpatient procedure.

• Highly effective: 85–90% of appropriately selected patients achieve long-term relief from heartburn and regurgitation and discontinue PPIs
• Requires careful patient selection (objective GERD confirmation by pH study; normal oesophageal motility; ideally reducible hiatal hernia)
• Side effects: dysphagia (usually transient), bloating, inability to belch (gas-bloat), dysphagia to solids in a minority
• Partial fundoplication (Toupet 270°) — less dysphagia risk; used in patients with impaired peristalsis

Magnetic Sphincter Augmentation (LINX device) — a ring of magnetic beads placed around the LOS laparoscopically; allows swallowing by separating, then closes to prevent reflux. Reversible; good outcomes; growing adoption.

Endoscopic anti-reflux procedures have different evidence bases and eligibility criteria. TIF may be considered for selected patients after objective assessment of GERD, oesophagitis and hiatal anatomy. Recommendations for radiofrequency treatment (Stretta) differ: the 2022 ACG guideline did not recommend it as an alternative to medical or surgical treatment because evidence was inconsistent; the 2025 ASGE guideline allows consideration in limited selected circumstances. A specialist should discuss the evidence, alternatives and uncertainty for the proposed procedure.

Barrett's Oesophagus — Surveillance and Endoscopic Treatment

Barrett's oesophagus (columnar metaplasia of the oesophagus) is a precursor to oesophageal adenocarcinoma. Management:

• PPI therapy — at least once daily is suggested by ACG for Barrett’s without contraindications; higher doses need a separate indication.
• Surveillance without dysplasia — after adequate baseline examination, ACG recommends 5-year intervals for segments <3 cm and 3-year intervals for segments ≥3 cm.
• Possible or confirmed dysplasia — requires expert pathology review and an earlier management plan. Indefinite dysplasia is reassessed within 6 months after treatment optimisation. For confirmed low-grade dysplasia, endoscopic eradication or close surveillance is discussed; surveillance, when chosen, starts at 6 and 12 months, then annually. High-grade dysplasia generally warrants eradication therapy.
• Endoscopic eradication therapy (EET) — may include radiofrequency ablation and resection of visible lesions by EMR or ESD. It requires specialist selection and follow-up; routine multi-year surveillance is not an adequate plan for untreated dysplasia.

GI and Reflux Care in China

Before arranging reflux care in China, ask the receiving team to confirm:

• Whether endoscopy, biopsies, pH-impedance testing or manometry are indicated and available.
• The exact acid-suppressing medicine, local indication, dose and follow-up plan.
• Whether surgery or a Barrett’s endoscopic treatment is appropriate and what risks apply.
• Any device availability, booking requirements, itemised hospital charges and separate coordination fees.
• Language support and continuity of care after travel.

Contact a PriumCare care navigator to arrange a reflux assessment, endoscopy, or anti-reflux surgery consultation.

---

Sources for these targeted corrections

• ACG GERD guideline.
• ACG Barrett’s oesophagus guideline.
• ACG oesophageal physiologic testing guideline.

Editorial source correction: 25 October 2026. This targeted check addressed flagged staging, trial results, test capabilities, treatment and surveillance claims. It is not a clinical review of the whole article. No named medical reviewer is claimed. Original publication date is retained.

Additional targeted source clarification

Editorial source check: 25 October 2026. These changes concern specific statistics and treatment-selection statements, not a whole-article medical review.

• Source 1
• Source 2
• Source 3
• Source 4