Gastroesophageal reflux disease

Last updated: July 25, 2023

Summarytoggle arrow icon

Gastroesophageal reflux disease (GERD) is a chronic condition in which stomach contents flow back into the esophagus, causing irritation to the mucosa. Reflux is primarily caused by an inappropriate, transient relaxation of the lower esophageal sphincter (LES). Risk factors include obesity, stress, certain eating habits (e.g., heavy meals or lying down shortly after eating), and changes in the anatomy of the esophagogastric junction (e.g., hiatal hernia). Typical symptoms are retrosternal burning pain (heartburn) and regurgitation, but the presentation is variable and may also include symptoms like chest pain and dysphagia. Most patients with suspected GERD should receive empirical treatment with proton pump inhibitors (PPIs). Diagnostic studies, e.g., esophagogastroduodenoscopy (EGD) and/or 24-hour pH test, may be indicated to confirm the diagnosis or to rule out other causes of symptoms. Management involves lifestyle modifications, medication, and, in some cases, surgery. Treating esophagitis is especially important because chronic mucosal damage can cause Barrett esophagus, a premalignant condition that can progress to adenocarcinoma.

Definitiontoggle arrow icon

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

GERD develops when reflux-promoting factors, such as corrosiveness of the gastric juice, overcome protective mechanisms, such as the gastroesophageal junction and esophageal acid clearance.


Risk factors for GERD

Pathologytoggle arrow icon

The histopathological findings include the following (may vary depending on the severity of mucosal damage): [11]

Clinical featurestoggle arrow icon

Typical symptoms

Atypical symptoms

Extraesophageal symptoms [15]

Aggravating factors

  • Lying down shortly after meals
  • Certain foods/beverages

Red flags in GERD [15]

Consider investigating epigastric pain or burning lasting > 1 month (see “Approach to dyspepsia”). [15][16]

Differential diagnosestoggle arrow icon

Rule out acute coronary syndrome in patients with atherosclerotic risk factors before making a clinical diagnosis of GERD.

The differential diagnoses listed here are not exhaustive.

Diagnosticstoggle arrow icon

There is no gold standard test for the diagnosis of GERD. The diagnosis is based on clinical presentation, endoscopic evaluation, reflux assessment, and therapeutic response. [15]

Approach [13][15]

Resolution of chest pain with antacids is not diagnostic for GERD and does not rule out life-threatening causes of chest pain. [18]

GERD is common during pregnancy and usually subsides after delivery; diagnostic workup is rarely necessary.

EGD [15][19][20][21]

> 50% of patients with GERD present with nonerosive reflux and normal endoscopic findings. [24]

Despite the limited value of esophageal biopsies in diagnosing GERD, they are necessary for establishing a diagnosis of eosinophilic esophagitis. [15]

Esophageal pH monitoring [15][22]

Esophageal pH monitoring can be used to objectively identify abnormal reflux of gastric content into the esophagus; however, it is not a routine diagnostic test. [15]

  • Indications
    • Refractory GERD symptoms despite PPI therapy
    • Confirmation of suspected NERD
    • Evaluation before surgical or endoscopic antireflux procedure
  • Procedure
    • Measurement of esophageal pH over 24–48 hours using a telemetry capsule or a transnasal catheter
    • Documentation of relevant events by the patient
  • Supportive finding: Drops in esophageal pH to 4 or less that correlate with symptoms of acid reflux and precipitating activities. [25]

Further diagnostic studies [15][22]

Not routinely indicated, as they play a limited role in the diagnosis of GERD; useful if endoscopy is inconclusive.

Treatmenttoggle arrow icon

The initial management of GERD consists of implementing lifestyle changes and initiating acid suppression therapy, preferably with PPIs. Surgical therapy is not routinely indicated and should only be considered in select cases, e.g., patients who develop complications despite receiving optimal medical therapy.

Pharmacological therapy [15][20]

See “Antacids and acid suppression medications” for agents, detailed dosages, and pharmacological considerations.

  • PPIs: : standard dose of PPI for 8 weeks
    • Indications
      • Empiric PPI trial in patients with typical symptoms
      • After EGD: ERD or presumed NERD
    • Continuous management (based on the clinical response after 8 weeks) [27]
      • Good response and no complications: Discontinue PPI.
      • Good response in patients with complications : Continue PPI at maintenance dose. [15]
      • Partial response: Increase dose (to twice-daily therapy), adjust timing, or switch to a different PPI.
      • Recurrence of symptoms after discontinuation of PPI or during weaning: Consider confirming the diagnosis (e.g., with ambulatory esophageal pH monitoring) prior to continuing maintenance therapy.
      • No response: further diagnostic evaluation
    • There is controversy surrounding the risks of long-term PPI therapy [28][29][30][31]
  • H2 receptor antagonists: Consider as alternate maintenance therapy for NERD, or in addition to PPIs to control nighttime symptoms
  • Maintenance therapy: lowest effective dose of acid suppression medication
  • Adjunctive therapy: Consider adding in patients with partial response to PPIs; Not recommended without confirmatory diagnostic studies

A negative response to a PPI trial does not exclude GERD.

Lifestyle changes [15][20][32][33][34]

There is conflicting evidence as to which lifestyle modifications confer a significant benefit. The following recommendations are commonly mentioned in the literature but should be approached on a case-by-case basis, as they may offer relief only for some patients.

  • Dietary recommendations
    • Small portions
    • Avoid eating at least 2–3 hours before bedtime.
    • Avoid foods and beverages that appear to trigger symptoms. [35]
  • Physical recommendations
    • Weight loss in patients with obesity
    • Elevate the head of the bed (10–20 cm) for patients with nighttime symptoms.
  • Reduce or avoid triggering substances

Surgical therapy [9][15][20][36]

Antireflux surgery may be considered for select patients after careful evaluation. Predictors of successful outcomes include: [37][38]


  • Discontinuation of medical therapy (e.g., due to nonadherence or side effects)
  • Symptoms refractory to medical therapy
  • Complications despite optimal medical therapy, e.g., severe esophagitis, strictures, recurrent aspiration
  • Large hiatal hernia


Complicationstoggle arrow icon

Barrett esophagus [20][39][40]

Endoscopic examination of the esophagus is indicated to screen for Barrett esophagus in men with chronic (> 5 years) and/or frequent (occurring at least weekly) GERD symptoms and ≥ 2 of the following risk factors: age > 50 years, white ethnicity, obesity, current or past history of smoking, family history of Barrett esophagus or esophageal adenocarcinoma.

Additional complications

We list the most important complications. The selection is not exhaustive.

Special patient groupstoggle arrow icon

Gastroesophageal reflux disease in infants

  • Etiology: persistent lower esophageal sphincter insufficiency
  • Clinical features
  • Diagnostics: based on clinical findings
    • H&P (e.g., presence of red flags in GERD, nutritional assessment, cow's milk and/or soy protein intolerance)
    • Imaging: may be indicated if symptoms after initiation of empirical treatment persist
  • Differential diagnoses: See GER in infants.
  • Treatment [43]
    • Conservative measures: lifestyle and dietary changes should be re-evaluated every 2–4 weeks
      • Positioning therapy: maintain the infant in an upright position for 20–30 minutes after feeding
      • If there is suspicion of cow's milk and/or soy protein intolerance:
        • Remove cow's milk or soy protein from the infant's diet
        • In breastfed infants, remove soy protein, cow's milk proteins, and beef from the mother's diet.
        • In formula-fed infants, substitute for a hypoallergenic formula
      • Using food thickeners
      • Avoid exposure to tobacco smoke [44]
    • Pharmacological treatment
    • Surgical treatment (complete or partial Nissen fundoplication): indicated in infants with complications from severe GERD who did not respond to conservative and pharmacological treatment

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Referencestoggle arrow icon

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