A practical guide to symptoms, risks and treatments

Gastro-oesophageal reflux disease (GORD) occurs when stomach contents reflux into the oesophagus (gullet). This can irritate the lining and cause a range of unpleasant symptoms.

Common symptoms include:

Heartburn—a burning sensation behind the breastbone
Regurgitation—the sensation of acid or food coming back up
Difficulty swallowing
Chronic cough or hoarseness
Throat symptoms such as sore throat or the sensation of something in the back of your throat
Acid brash – a metallic taste in your mouth
Dental erosions – from acid eroding your teeth
Choking during sleep

Long-term Risks of Gastro-oesophageal Reflux Disease

🔥 Oesophagitis

Repeated acid exposure can inflame and damage the lining of the oesophagus, causing pain, bleeding, ulceration, or worsening swallowing symptoms.

🩹 Oesophageal ulceration

Severe reflux inflammation can lead to ulceration, which may cause pain, bleeding, anaemia, or need for endoscopic assessment.

🚧 Oesophageal stricture

Chronic inflammation can cause scarring and narrowing of the oesophagus, leading to progressive dysphagia and sometimes requiring endoscopic dilatation.

🧬 Barrett’s oesophagus

Long-standing reflux can cause a change in the lining of the lower oesophagus. Barrett’s oesophagus is important because it increases the risk of oesophageal adenocarcinoma.

⚠️ Oesophageal adenocarcinoma

This is a rare but serious complication. Risk is higher in people with Barrett’s oesophagus and other risk factors such as long symptom duration, frequent reflux, hiatus hernia, obesity, and male sex.

🫁 Extra-oesophageal complications

Reflux can be associated with chronic cough, hoarseness, throat symptoms, asthma-like symptoms, aspiration, or laryngopharyngeal symptoms, although proving reflux as the cause can be difficult.

🌙 Sleep disturbance and reduced quality of life

Night-time reflux can disturb sleep and contribute to fatigue, impaired daily functioning, and persistent symptom burden.

Why does reflux happen?

Nearly all people will experience reflux in their lifetime. Patients who require treatment develop what we term pathological reflux, i.e. the amount of reflux they get is abnormal and becomes a disease in itself.

1 in 5 people suffer with symptoms of Gastro—Oesophageal Reflux Disease (GORD) in the UK. This is where the amount of acid and duration of refluxing into your oesophagus from your stomach is abnormal.

We all possess multiple mechanisms that prevent us normally suffering from reflux.

1) The angle of His—this is the sharp angulation the oesophagus and stomach take before entering the stomach’s main body

2) The lower oesophageal sphincter—a condensation of muscle at the end of our oesophagus that relaxes to allow food into the stomach and closes to prevent acid and food coming back up the oesophagus

3) Healthy oesophageal mucosa that secretes small amounts of bicarbonate to neutralize acid and also a type of cellular ‘bilge’ pump that pumps small amounts of acid away

4) Good oesophageal motility – Your oesophagus or gullet carries food from your mouth to your stomach by a coordinated squeezing motion known as peristalsis. This allows good acid clearance when acid does reflux into your oesophagus from the stomach.

Quite often in the presence of a hiatus hernia (sometimes without one) these barriers above fail. Acid then gets sucked up into the oesophagus when our chests expand. Normally our chests expand to generate a negative pressure in the chest, to neutralise this pressure air rushes into our lungs — however this has the unintended consequence when part of the stomach is in the chest (hiatus hernia) of then encouraging acid to shoot up into our throats. Sometimes this acid also goes into our lungs and is now a recognized cause of pulmonary fibrosis (scarring of the lungs), indeed lung transplant teams often ask us to assess patients for acid reflux and offer antireflux surgery before they will perform a lung transplant in order to protect the new lung.

WHEN TO SEEK MEDICAL ADVICE

Speak to a specialist if you experience:

Symptoms more than twice a week

Night time symptoms disturbing sleep

Difficulty swallowing

Unexplained weight loss

Ongoing need for medication

Persistent reflux can lead to complications such as oesophagitis, Barrett’s oesophagus, and rarely cancer

Lifestyle advice to decrease reflux

Reduce your BMI to a healthy BMI; we know that many patients whom reduce their BMI below 32 will see a reduction in their reflux symptoms

Stop smoking – smoking is often associated with acid reflux and also failure of treatments for reflux

Reduce caffeine, spicy foods and alcohol

Avoid fizzy drinks

Do not eat less than 3 hours before bed

Do not have warm drinks less than 2 hours before bed

Sleep with multiple pillows or supports to keep you more upright

Treatments for Acid reflux:

Despite all these lifestyle modifications many patients will need treatment for their acid reflux. Treatments that our routinely used are long term medication or anti reflux surgery.

Long term medication is in the form of the proton pump inhibitors such as :

Omeprazole (Losec)
Lansoprazole (Zoton)
Pantoprazole (Protium)
Esomeprazole (Nexium)
Rabeprazole (Pariet)

Sometimes a histamine-2 receptor antagonist is used, most commonly famotidine. In current UK practice, famotidine is generally favoured because ranitidine has been discontinued and is not currently available in the UK or globally following concerns about an impurity that may cause harm, while other H2 blockers such as cimetidine and nizatidine are less commonly used because of local formulary restrictions, availability, interaction burden, and preference for famotidine as the practical alternative when an H2 blocker is required.

Generally the histamine-2 receptor antagonists are seen as less effective to PPIs for acid reflux.

A number of concerns are being raised with regard to PPI therapy and patients commonly ask me about them in clinic. I have summarised the current evidence and common questions about risk in table 1.

Table 1: Risks of Long-term Proton Pump Inhibitor Therapy

Potential risk

Clinical relevance / evidence summary

🦠 Enteric infection, especially Clostridioides difficile

Long-term acid suppression is associated with increased susceptibility to enteric infection; risk is most important in older, hospitalised, antibiotic-exposed, or immunocompromised patients.

🫁 Community-acquired pneumonia

Observational studies report an association, particularly around initiation of therapy; causality is uncertain and confounding is likely.

⚡ Hypomagnesaemia

Prolonged therapy may reduce magnesium levels, sometimes causing clinically significant hypomagnesaemia; consider monitoring in high-risk patients or those taking diuretics or digoxin.

🩸 Vitamin B12 deficiency and anaemia

Reduced gastric acidity may impair release of vitamin B12 from food; risk is more relevant with prolonged use, older age, restricted diet, malabsorption, or metformin therapy.

🦴 Fracture risk / osteoporosis-related fractures

Long-term PPI use has been linked in observational data with hip, wrist, and spine fractures. The absolute risk is usually low, but review is prudent in patients with other osteoporosis risks.

🫘 Kidney injury and chronic kidney disease

Associations include acute interstitial nephritis, acute kidney injury, chronic kidney disease, and end-stage kidney disease. Causality is not always established, but unexplained renal decline should prompt review.

↩️ Rebound acid hypersecretion on stopping

Stopping long-term therapy can cause transient dyspepsia, reflux, or upper gastrointestinal symptoms; tapering or abrupt discontinuation may both be considered depending on the clinical context.

⚠️ Possible dementia, cardiovascular events, and cancers

These outcomes have been reported in observational studies, but evidence is inconsistent and confounding is a major limitation; they should not be used alone as a reason to stop an indicated PPI.

Most long-term PPI safety concerns are based on observational associations rather than definitive proof of causation. Current best practice is to review the indication regularly, use the lowest effective dose, and consider deprescribing only when there is no clear ongoing indication. Consideration should always be given as to whether daycase keyhole antireflux surgery is a better long-term option on an individual patient basis in conjunction with an expert.

Why is my reflux medication not working anymore?

21.8 million patients are estimated to be on PPIs with 40% still having symptoms.

This is a common phenomenon and misunderstanding by Doctor and patient alike; medications for reflux do not stop reflux. They reduce the acidity of reflux; patients tend to be less symptomatic from non acidic reflux. However over time in some patients the sheer volume of reflux becomes the problem not the acidity. An example of this is when patients lie flat, the refluxate works its way up to their mouth and airway. This irritates their throat leading to a choking sensation in their sleep and sometimes even vomit being present on their cheek – here the problem is not the acidity it is the volume of refluxate.

Surgical Treatments for Antireflux Surgery

All surgeries I offer are daycase keyhole (laparoscopic procedures) under general anaesthetic. 95% of my patients are happy they had their surgery at 5 years and would recommend it to family or friends. They can be used for both acid reflux and volume reflux effectively.

Both surgeries involve the repair of the hiatus hernia if present and the restoration of normal anatomy via keyhole incisions. I then perform an antireflux procedure; the two below being the most common:

LINX magnetic sphincter augmentation

This is a minimally invasive laparoscopic procedure in which a small ring of interlinked titanium beads with magnetic cores is placed around the lower oesophageal sphincter. The magnetic attraction helps the sphincter remain closed at rest to reduce reflux, while allowing it to open during swallowing, belching and vomiting. The LINX device adds about 15mmHg of mercury pressure to reinforce the weakened lower oesophageal sphincter.

12 year follow up data placed 91% of patients being free from daily antireflux medication at 12 years following LINX insertion.

The main benefits of LINX are improved reflux control, reduced regurgitation, improved health-related quality of life and less reliance on long-term acid-suppression medication.

Laparoscopic fundoplication

This is the traditional operative treatment for proven GORD and is usually performed as a day-case or short-stay keyhole procedure. The upper part of the stomach is wrapped around the lower oesophagus to reinforce the antireflux barrier. The wrap may be complete, such as a 360-degree Nissen fundoplication, or partial, such as a posterior Toupet fundoplication, depending on symptoms, oesophageal motility and patient preference.

The principal benefits of fundoplication are durable reflux control, reduced heartburn and regurgitation, healing or prevention of reflux oesophagitis, reduced need for proton pump inhibitors, and improved disease-specific quality of life in appropriately selected patients with objective evidence of reflux. It is particularly useful where reflux is associated with a significant hiatus hernia or when long-term medication is ineffective, poorly tolerated, or undesirable.

Overall, patient outcomes after antireflux surgery are best when there is careful pre-operative selection, including confirmation of pathological reflux and assessment of oesophageal motility. Both LINX and fundoplication can substantially improve reflux symptoms and quality of life.