Gastro-oesophageal reflux disease (GORD; GERD in US usage) occurs when gastric contents flow back into the oesophagus frequently enough or for long enough to cause troublesome symptoms or damage to the oesophageal lining. Typical symptoms: heartburn (retrosternal burning, often after meals or lying down); acid regurgitation (sour or bitter fluid reaching the throat or mouth). Less typical: chest pain (must exclude cardiac causes first); chronic cough; hoarseness; globus. Approximately 13% of adults worldwide have weekly symptoms. Risk factors: obesity (the strongest modifiable factor); hiatus hernia; pregnancy; smoking; certain medications (calcium channel blockers, nitrates, anticholinergics).

Are long-term PPIs safe?

PPIs are effective and generally well tolerated, but long-term use without a clear indication should be avoided. Observational studies have reported associations with: fracture; hypomagnesaemia; vitamin B12 deficiency; Clostridioides difficile infection; community-acquired pneumonia; chronic kidney disease. Most of these associations are of uncertain causality (confounding by indication is a major limitation), and the large randomised COMPASS safety substudy (Gastroenterology 2019, 17,598 patients, 3 years) found no significant increase in any of these outcomes except enteric infections. The pragmatic conclusion: PPIs remain appropriate where indicated, but every patient on long-term PPI should have the indication reviewed annually, with a trial of step-down, on-demand or discontinuation where the original indication was uncomplicated reflux. Indefinite PPI is appropriate for: Barrett's oesophagus; severe erosive oesophagitis; peptic stricture; long-term NSAID use with risk factors.

When do I need an endoscopy?

Urgent upper GI endoscopy is required for any alarm feature: dysphagia (difficulty swallowing — the most important); odynophagia (painful swallowing); unintentional weight loss; iron deficiency anaemia; persistent vomiting; upper GI bleeding (vomiting blood, black tarry stools); palpable epigastric mass; new-onset dyspepsia over the age of 55 (or lower thresholds in regions with high gastric cancer incidence). Endoscopy is also appropriate for: symptoms refractory to adequate PPI therapy; before considering antireflux surgery; screening for Barrett's in patients with chronic GORD plus multiple risk factors (male sex, age >50, white ethnicity, obesity, smoking, family history of Barrett's or oesophageal adenocarcinoma).

Why is my PPI not working?

Several possibilities, in order of likelihood: (1) Incorrect timing — PPIs must be taken 30-60 minutes before a meal, not at bedtime on an empty stomach. This is the single most common correctable cause of apparent PPI failure. (2) The symptoms are not acid-mediated — functional heartburn or reflux hypersensitivity, which require neuromodulators rather than more acid suppression. (3) Non-acid or weakly acidic reflux (bile reflux) — pH-impedance testing distinguishes this. (4) An alternative diagnosis — eosinophilic oesophagitis (increasingly recognised, particularly in younger patients with dysphagia and food impaction; requires oesophageal biopsies), achalasia, cardiac chest pain, peptic ulcer, gastric cancer. (5) CYP2C19 rapid metaboliser status. The correct next step in true PPI non-response is objective testing (endoscopy with biopsies, then pH-impedance and manometry) — not indefinite dose escalation.

What is Barrett's oesophagus and how serious is it?

Barrett's oesophagus is a change in the lining of the lower oesophagus, where the normal squamous epithelium is replaced by intestinal-type columnar epithelium in response to chronic acid exposure. It occurs in approximately 5-15% of people with chronic GORD. Barrett's is a precursor to oesophageal adenocarcinoma — but the annual progression risk for non-dysplastic Barrett's is low (approximately 0.1-0.3% per year), substantially lower than historically taught. Management: lifelong PPI; surveillance endoscopy every 3-5 years with Seattle protocol biopsies; if low-grade dysplasia is confirmed by two expert pathologists, radiofrequency ablation is now preferred over continued surveillance (SURF trial: reduced progression from 26.5% to 1.5%); high-grade dysplasia or early cancer is treated endoscopically (EMR + RFA) rather than by oesophagectomy in most cases.

How does GMJ News cover GORD?

GMJ News covers GORD epidemiology, PPI pharmacology and the critical pre-meal timing rule, PPI deprescribing and the COMPASS safety data, alarm features mandating endoscopy, LA classification of oesophagitis, pH-impedance testing, functional heartburn vs reflux hypersensitivity vs true GORD, Barrett's surveillance and RFA (SURF trial), extra-oesophageal reflux and the weakness of that evidence base, eosinophilic oesophagitis as a differential, and surgical options. Directly relevant to PHIG's gastroenterology and primary care prescribing quality programme.

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Gastro-oesophageal Reflux Disease

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Gastro-oesophageal reflux disease (GORD, GERD in US usage) — the retrograde flow of gastric contents into the oesophagus causing troublesome symptoms or mucosal complications — affects an estimated 13% of the global adult population weekly and is one of the most common conditions managed in primary care worldwide, driven by transient lower oesophageal sphincter relaxations, hiatus hernia, obesity and delayed gastric emptying (WHO). Proton pump inhibitors (PPIs) remain the most effective medical therapy — but the modern clinical challenge is the opposite of undertreatment: long-term PPI use without a clear indication is now a major deprescribing target, with observational associations reported for fracture, hypomagnesaemia, vitamin B12 deficiency, Clostridioides difficile infection and chronic kidney disease, alongside the important minority of patients whose reflux symptoms are not acid-mediated at all and will never respond to acid suppression.

Key messages

13% of adults have weekly reflux symptoms — one of the most common conditions in primary care

GORD affects approximately 13% of the global adult population weekly (systematic review, Gut 2018). Prevalence is rising with obesity. Mechanisms: transient lower oesophageal sphincter relaxations (the dominant mechanism); hiatus hernia (impairs the crural diaphragm sphincter contribution); obesity (increased intra-abdominal pressure); delayed gastric emptying; reduced oesophageal acid clearance.

PPI deprescribing — the modern clinical priority

Long-term PPI use without a clear ongoing indication is now a major deprescribing target. Observational associations reported: fracture risk; hypomagnesaemia; vitamin B12 deficiency; Clostridioides difficile infection; community-acquired pneumonia; chronic kidney disease; dementia (weakest signal). Causality is uncertain for most — but the principle is clear: prescribe the lowest effective dose for the shortest necessary duration, review annually, and attempt step-down or on-demand dosing in uncomplicated GORD. Indications for indefinite PPI: Barrett's oesophagus; severe erosive oesophagitis (LA grade C/D); peptic stricture; Zollinger-Ellison; long-term NSAID use with risk factors.

Alarm features mandate endoscopy — do not treat empirically

Red flags requiring urgent upper GI endoscopy: dysphagia (the most important — suggests stricture or malignancy); odynophagia; unintentional weight loss; iron deficiency anaemia; persistent vomiting; upper GI bleeding (haematemesis, melaena); palpable epigastric mass; age >55 with new-onset dyspepsia (threshold varies by country and background gastric cancer incidence — lower in high-incidence regions). Empirical PPI therapy in a patient with alarm features risks masking oesophageal or gastric malignancy.

Not all reflux symptoms are acid-mediated

A substantial minority of patients with reflux symptoms have: functional heartburn (no reflux, no acid correlation — a disorder of gut-brain interaction, treat with neuromodulators not PPIs); reflux hypersensitivity (physiological acid exposure but symptom correlation); non-acid or weakly acidic reflux (bile reflux). These patients will never respond adequately to acid suppression. Investigation: oesophageal pH-impedance monitoring off PPI (measures acid exposure time and symptom association probability) + high-resolution manometry. Escalating PPI dose in a non-responder without objective testing is a common and unproductive pattern.

Barrett's oesophagus — the premalignant complication

Barrett's oesophagus: replacement of normal squamous oesophageal epithelium with intestinal-type columnar (specialised intestinal metaplasia) — a response to chronic acid exposure. Prevalence: approximately 5-15% of patients with chronic GORD. Risk of progression to oesophageal adenocarcinoma: approximately 0.1-0.3% per year for non-dysplastic Barrett's (much lower than historically believed). Surveillance endoscopy: every 3-5 years for non-dysplastic (segment-length dependent). Low-grade dysplasia: endoscopic radiofrequency ablation (RFA) is now preferred over surveillance (SURF trial). High-grade dysplasia or intramucosal cancer: endoscopic resection (EMR/ESD) + RFA.

Lifestyle and surgical options

Evidence-based lifestyle measures: weight loss (the single most effective — strong evidence); elevate head of bed 15-20cm (for nocturnal symptoms); avoid eating within 3 hours of lying down; smoking cessation. Weak or no evidence: blanket avoidance of coffee, chocolate, citrus, spicy food, alcohol (individualise — advise avoiding personally identified triggers rather than blanket restriction). Surgery: laparoscopic Nissen or Toupet fundoplication — for patients with objectively confirmed GORD who are PPI-responsive but wish to avoid lifelong medication, or with volume regurgitation refractory to PPI. Magnetic sphincter augmentation (LINX) is an alternative. Do not operate on functional heartburn — outcomes are poor.

Key statistics

~13%

of global adults have weekly GORD symptoms

Gut 2018 meta-analysis

Dysphagia

the single most important alarm feature — mandates urgent upper GI endoscopy

NICE/ACG

5-15%

of chronic GORD patients develop Barrett's oesophagus

ACG/BSG

0.1-0.3%/yr

progression rate from non-dysplastic Barrett's to oesophageal adenocarcinoma

NEJM/BSG

Weight loss

the single most effective lifestyle intervention for GORD — strong evidence

ACG 2022

SURF trial

radiofrequency ablation preferred over surveillance for low-grade dysplastic Barrett's

JAMA 2014

GORD management — evidence strength by intervention (ACG 2022)

Source: ACG 2022. Weight loss and PPI have the strongest evidence; blanket dietary restriction has weak evidence.

Glossary of key terms

Los Angeles (LA) classification of oesophagitis
EndoscopyThe standard endoscopic grading of erosive oesophagitis: Grade A — one or more mucosal breaks ≤5mm, not extending between the tops of two mucosal folds. Grade B — mucosal break >5mm, not extending between two mucosal folds. Grade C — mucosal break continuous between the tops of ≥2 mucosal folds, involving <75% of the circumference. Grade D — mucosal break involving ≥75% of the oesophageal circumference. LA grade A alone is not diagnostic of GORD (found in some asymptomatic individuals); LA grades C and D confirm GORD definitively and mandate long-term PPI and repeat endoscopy after healing to exclude underlying Barrett's.

Oesophageal pH-impedance monitoring
Physiology/GIThe objective test for GORD — a transnasal catheter (or wireless Bravo capsule) measures oesophageal pH and impedance (which detects all reflux events including non-acid and gas). Key metrics: acid exposure time (AET — % of time pH <4; >6% abnormal, <4% normal); total reflux episodes; symptom association probability (SAP) and symptom index (SI) — correlating patient-marked symptom events with reflux episodes. Performed OFF PPI (7 days) when the diagnosis of GORD itself is in question; ON PPI when investigating refractory symptoms in confirmed GORD. Distinguishes: true GORD; reflux hypersensitivity (normal AET, positive SAP); functional heartburn (normal AET, negative SAP).

PPI pharmacology and dosing
PharmacologyPPIs (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole) irreversibly inhibit the gastric H+/K+-ATPase proton pump. Critical dosing point: PPIs must be taken 30-60 minutes BEFORE a meal — they only inhibit actively secreting pumps, so require postprandial pump activation for maximal effect. Taking a PPI at bedtime on an empty stomach substantially reduces efficacy — a very common and easily corrected error. Onset of full effect: 3-5 days (steady state). CYP2C19 polymorphism: poor metabolisers have higher exposure; rapid metabolisers may need higher dose or a less CYP2C19-dependent PPI (rabeprazole, pantoprazole). Clopidogrel interaction: omeprazole and esomeprazole inhibit CYP2C19-mediated clopidogrel activation — use pantoprazole if a PPI is needed with clopidogrel.

Barrett's surveillance and endoscopic therapy
BSG/ACGNon-dysplastic Barrett's: surveillance endoscopy every 3-5 years (BSG: 3-5 years for segments <3cm; 2-3 years for ≥3cm), with Seattle protocol biopsies (4-quadrant every 2cm plus targeted biopsy of any visible lesion). Indefinite for dysplasia: optimise acid suppression, repeat endoscopy in 6 months. Low-grade dysplasia (confirmed by 2 expert GI pathologists): radiofrequency ablation (RFA) — SURF trial showed RFA reduced progression to high-grade dysplasia/cancer from 26.5% to 1.5% vs surveillance. High-grade dysplasia or intramucosal adenocarcinoma: endoscopic mucosal resection (EMR) of visible lesions + RFA of residual Barrett's. Oesophagectomy: now reserved for submucosal invasion or endoscopically unresectable disease.

Extra-oesophageal reflux
ENT/Respiratory/GIReflux is implicated in: chronic cough; laryngitis and hoarseness ("laryngopharyngeal reflux" — LPR); asthma; dental erosion; globus sensation. The evidence base is much weaker than commonly assumed: multiple RCTs of PPI for chronic cough and LPR have been negative or marginal, and the ENT signs traditionally attributed to reflux (posterior laryngeal erythema, oedema) are highly non-specific and present in most asymptomatic individuals. Guidance (ACG 2022): do not diagnose extra-oesophageal reflux on laryngoscopy findings alone; do not treat with prolonged empirical high-dose PPI without objective reflux testing; consider alternative causes (asthma, post-nasal drip, ACE inhibitor cough, vocal misuse).

Functional heartburn
Rome IV/GIFunctional heartburn (Rome IV): retrosternal burning discomfort or pain, refractory to optimal acid suppression, with NO evidence of GORD (normal endoscopy, normal acid exposure time on pH-impedance) and NO symptom-reflux association, and no major oesophageal motility disorder. Symptoms ≥2 days/week for ≥3 months. It is a disorder of gut-brain interaction (visceral hypersensitivity + central pain processing). Treatment: stop or step down the PPI (it does not work and adds risk); neuromodulators (low-dose tricyclic antidepressants — amitriptyline 10-25mg nocte; SSRIs; trazodone); gut-directed hypnotherapy; CBT. Do not offer antireflux surgery — outcomes are consistently poor.