Gastro-oesophageal Reflux Disease

Gastro-oesophageal reflux is the backflow of stomach contents into the oesophagus. Occasional, short-lived burning or bitter fluid coming up into the mouth can also occur in healthy people. If this happens frequently, affects daily life or sleep, or causes damage to the oesophagus, it is called “gastro-oesophageal reflux disease”.

Between the oesophagus and the stomach there is a muscular structure called the lower oesophageal sphincter. This area is not a valve on its own; the diaphragm muscles, the part of the oesophagus inside the abdomen and the anatomy of the junction between the stomach and the oesophagus together form a barrier.

Temporary relaxation or inadequate function of this barrier, a hiatus hernia, increased pressure inside the abdomen and impaired clearing movements of the oesophagus can make reflux more likely.

The contents coming up from the stomach do not consist only of acid. Bile and digestive juices can also be present in the refluxed material. For this reason, in some patients, fluid or food coming up into the mouth in particular may continue despite acid-suppressing medicines.

In most people, reflux disease can be controlled with lifestyle changes and medicines. Some patients, however, may need long-term treatment, an endoscopic procedure or surgery. Treatment should be individualised according to the type of symptoms and whether reflux has been objectively demonstrated [1–4].

What are the typical symptoms of reflux?

The two most common symptoms are:

• Heartburn: Usually felt behind the breastbone, and it can rise from the stomach area towards the throat.
• Regurgitation: Stomach contents, bitter or sour fluid, or food coming back up into the mouth without nausea.

The following complaints may also be related to reflux:

• Discomfort in the chest or over the stomach after meals
• Waking from sleep at night with burning or fluid coming up into the mouth
• Complaints that get worse on bending over or lying down
• A feeling of food sticking when swallowing
• Chest pain
• A sour or bitter taste in the mouth

Can a cough and hoarseness be caused by reflux?

In some people, reflux may be accompanied by:

• A long-lasting cough
• Hoarseness
• A need to clear the throat
• A burning or sticking sensation in the throat
• Asthma-like complaints
• Wear of the tooth enamel

However, these symptoms are not specific to reflux. Allergies, postnasal drip, asthma, smoking, diseases of the vocal cords and certain medicines can also cause the same complaints.

Having only a cough, throat complaints or hoarseness, without heartburn or bitter fluid coming up into the mouth, is not sufficient to diagnose reflux. In these patients, it is recommended that other causes be investigated and, if necessary, reflux be confirmed with tests before starting unnecessary and long-term reflux treatment [2–4].

Which conditions can make reflux more likely?

The main factors that can make reflux more likely are:

• Excess weight and obesity
• Hiatus hernia
• Pregnancy
• Lying down shortly after eating
• Eating late at night
• Large and fatty meals
• Smoking
• Certain medicines
• Slow emptying of the stomach
• Movement disorders of the oesophagus

Chocolate, coffee, spices, tomatoes, citrus fruits, fizzy drinks or alcohol can make complaints worse in some people. However, not every patient needs to give up all of these foods. The current approach is for people to limit the foods they notice clearly make their own complaints worse [1,2].

What is a hiatus hernia?

A hiatus hernia is the movement of the upper part of the stomach through the opening in the diaphragm towards the chest cavity. Small hiatus hernias may cause no symptoms. Large hernias, however, can increase reflux, fullness after meals, chest pain or difficulty swallowing.

Not every hiatus hernia requires surgery. The decision is made according to the type and size of the hernia, the patient’s complaints, reflux tests and any complications that have developed.

Does every reflux patient need an endoscopy?

No. In patients with typical complaints such as heartburn and bitter fluid coming up into the mouth, and with no alarm symptoms, treatment can be started at first without an endoscopy.

Current guidelines generally recommend that these patients try an 8-week course of a proton pump inhibitor taken once a day [1,2].

Endoscopy is considered particularly in the following situations:

• Difficulty swallowing
• Weight loss
• Bleeding from the digestive tract or anaemia
• Repeated vomiting
• Complaints that continue despite medication
• Suspected severe inflammation of the oesophagus
• More than one risk factor for Barrett’s oesophagus
• Planned surgical or endoscopic reflux treatment

A normal endoscopy does not completely rule out reflux disease. In a large proportion of reflux patients, no damage to the oesophagus is seen on endoscopy.

What is assessed during endoscopy?

During endoscopy, the following are assessed:

• Inflammation and ulcers in the oesophagus
• Narrowing of the oesophagus
• Barrett’s oesophagus
• Hiatus hernia
• The structure of the junction between the stomach and the oesophagus
• Diseases other than reflux

Reflux damage in the oesophagus is usually graded according to the Los Angeles classification. According to the current Lyon Consensus 2.0, Los Angeles grade B, C or D oesophagitis is regarded as one of the strong findings supporting reflux disease [3].

If an area suggestive of Barrett’s oesophagus is seen during endoscopy, a biopsy may be taken. By contrast, a routine biopsy from a normal-looking oesophagus is not necessary in every reflux patient.

What is a 24-hour pH or pH-impedance test?

Reflux monitoring tests measure the amount of stomach contents flowing back into the oesophagus and their relationship to the complaints.

A thin catheter can be placed through the nose into the oesophagus, or a temporary wireless capsule can be attached to the oesophagus during endoscopy. pH-impedance measurement can assess both acid and non-acid reflux episodes.

Whether the test is done while taking medication or after stopping it depends on the patient’s situation:

• If reflux has not previously been objectively proven: The measurement is usually done after stopping acid-suppressing medicines.
• If reflux has previously been clearly demonstrated but complaints continue despite treatment: In some patients, pH-impedance measurement may be done while continuing medication.

The doctor should decide how long the medicines are to be stopped. Patients should not stop their medicines on their own before the test [2–4].

What is oesophageal manometry?

Manometry measures how the muscles of the oesophagus work and the pressure pattern at its junction with the stomach.

Manometry alone does not diagnose reflux. It is used particularly:

• In people with difficulty swallowing
• In people for whom reflux surgery is planned
• When the pH catheter needs to be positioned correctly
• When a movement disorder such as achalasia is suspected

Before reflux surgery, it is important to rule out serious movement disorders of the oesophagus, because some patients thought to have reflux may have conditions such as achalasia that require completely different treatment.

When is a barium swallow used?

A barium swallow is not the main test used to demonstrate reflux definitively. However, it may be useful when there is suspicion of:

• A large hiatus hernia
• Narrowing of the oesophagus
• A swallowing disorder
• An anatomical problem after surgery

Is every burning sensation that does not improve with medicines reflux?

No. Burning that continues despite medication may be caused by:

• Taking the medicine at the wrong time or irregularly
• Non-acid reflux
• Reflux hypersensitivity
• Functional heartburn
• Eosinophilic oesophagitis
• Achalasia or other movement disorders
• Heart disease
• Gallbladder or other digestive system problems

For this reason, in patients who do not respond to treatment, the diagnosis needs to be reassessed rather than simply increasing the dose repeatedly or going straight to planning surgery [3,4].

Which lifestyle changes may be helpful?

Rather than giving everyone the same list of prohibitions, measures with stronger scientific support that suit the individual should be chosen.

The main recommendations are:

• Losing weight if you are overweight
• Not lying down for at least 2–3 hours after eating
• Raising the head of the bed by about 15–20 centimetres if you have night-time complaints
• Raising the upper part of the bed rather than only adding more pillows
• Eating smaller meals instead of large and fatty ones
• Not eating late at night
• Not smoking
• Limiting foods and drinks that clearly make the complaints worse
• Avoiding clothing that is very tight around the waist and abdomen

In some people with night-time reflux, lying on the left side can reduce complaints. Lying on the right side, on the other hand, can increase reflux in some patients.

How should reflux medicines be taken?

The most effective group of medicines in reflux treatment is the proton pump inhibitors. These medicines reduce the production of stomach acid and help inflammation in the oesophagus to heal.

Generally, it is recommended that they be taken:

• 30–60 minutes before breakfast if taken once a day
• 30–60 minutes before breakfast and the evening meal if taken twice a day

Taking the medicine at the right time can significantly affect the success of treatment. In a patient whose complaints continue, the timing of use and adherence to treatment should be checked before the dose is increased or the medicine is changed [2].

Antacids and medicines containing alginate can provide short-term relief for mild or occasional complaints. Histamine-2 receptor blockers can be used in some patients, but proton pump inhibitors are more effective in healing severe oesophagitis.

How long should reflux medicines be taken?

In patients with typical reflux complaints, initial treatment usually lasts about 8 weeks. Once the complaints are under control, the following may be considered depending on the patient’s situation:

• Stopping the medicine
• Taking it as needed
• Switching to a lower dose
• Continuing at the lowest effective dose

Long-term treatment is needed in some patients with severe oesophagitis, Barrett’s oesophagus, an oesophageal ulcer or narrowing. In these patients, it is not appropriate to stop the medicines haphazardly [2,5].

Are proton pump inhibitors safe?

Proton pump inhibitors are generally safe medicines when used for an appropriate reason.

There are observational studies reporting an association between these medicines and kidney disease, bone fractures, vitamin deficiency, infections and forgetfulness. However, most of these studies do not prove a direct cause-and-effect relationship.

According to current guidelines, in patients who need treatment, the benefit of proton pump inhibitors generally outweighs their proven risks. On the other hand, it is not right to use them unnecessarily, without proper assessment and for an indefinite period [2,5].

The need for treatment and the dose should be reviewed at regular intervals. After the medicine is stopped suddenly, a temporary increase in acid secretion and a return of complaints may occur. For this reason, any plan to stop or reduce the dose should be made together with the doctor.

Who can have reflux surgery?

Reflux surgery is considered in selected patients whose reflux has been demonstrated by objective tests and who are likely to benefit from surgery.

Surgery may be considered particularly in the following situations:

• Reflux clearly demonstrated by endoscopy or pH measurement
• The presence of a large hiatus hernia
• Severe reflux oesophagitis
• Regurgitation that continues despite medication and is objectively related to reflux
• Suitable patients whose symptoms improve with medication but who prefer surgery to long-term treatment
• Narrowing or other complications due to reflux
• Marked impairment of quality of life despite appropriate treatment

In patients who have only a cough, a burning throat or hoarseness and whose reflux has not been confirmed by tests, the likelihood of successful surgery is lower.

A complete lack of response to medication also does not automatically mean that surgery is needed. On the contrary, in this situation it should be investigated in detail whether the complaints are really caused by reflux.

Which tests are done before surgery?

Before reflux surgery, the following are usually used:

• Endoscopy
• pH or pH-impedance measurement if reflux has not been objectively proven
• Oesophageal manometry
• A barium swallow and/or CT of the chest and abdomen if there is a large hernia or an anatomical problem

For the success of surgery, correct patient selection is as important as the surgical technique. It is not appropriate to operate based only on complaints without objective evidence of reflux [2,3,6].

What is fundoplication surgery?

Fundoplication strengthens the reflux barrier by wrapping the upper part of the stomach around the lower end of the oesophagus. If there is a hiatus hernia, it is brought back down into the abdomen and the widened opening in the diaphragm is repaired.

The main types of fundoplication are:

• Total fundoplication: The upper part of the stomach is wrapped completely around the oesophagus. The best-known method is Nissen fundoplication.
• Partial fundoplication: The stomach is wrapped partly around the oesophagus. Toupet and Dor fundoplications belong to this group.

Total fundoplication can provide stronger reflux control in some patients. With partial fundoplication, on the other hand, the risk of long-lasting difficulty swallowing and gas bloating after surgery may be lower.

The current SAGES guideline recommends that the choice between total and partial fundoplication be made as a shared decision based on oesophageal motility, the patient’s priorities and the surgeon’s assessment [6].

The operation is usually performed laparoscopically. The robotic method can also be used, but it is not necessary for every patient. The surgeon’s experience and a safe repair are more important than the form of the method used.

Are there other interventional methods for reflux?

In selected patients, the following methods may be considered:

• Magnetic sphincter augmentation: Supporting the reflux barrier with a ring system made of magnetic beads placed at the lower end of the oesophagus.
• Transoral incisionless fundoplication: Strengthening the junction between the stomach and the oesophagus with an endoscopic device passed through the mouth.
• Other endoscopic reflux treatments: These can be used in selected patients with suitable anatomy and confirmed reflux.

These methods are not suitable for every patient. The presence of a large hiatus hernia, severe oesophagitis, Barrett’s oesophagus or a serious oesophageal movement disorder affects the choice of treatment.

The long-term results of endoscopic methods may not be as extensively documented as those of classic fundoplication. The treatment decision should be made by an experienced team [1].

Which operation is preferred in patients with obesity?

In some patients with obesity and severe reflux who meet the criteria for obesity surgery, Roux-en-Y gastric bypass may be considered for both weight loss and reflux control.

Sleeve gastrectomy, on the other hand, can increase reflux or lead to new reflux in some patients. For this reason, the choice of method should be made carefully in reflux patients for whom obesity surgery is planned.

Related operationAnti-Reflux Surgery →Read how the operation is performed and what recovery involves →

How long do you stay in hospital after reflux surgery?

After laparoscopic reflux surgery, the hospital stay is usually 1–2 days. Repair of a large hiatus hernia, other illnesses or the course of the operation can change this time.

How should you eat after the operation?

In the first days, you can start with liquid or soft foods. Diet is gradually returned to normal according to the surgical team’s advice.

During the recovery period, the following may be helpful:

• Taking small bites
• Chewing food very well
• Eating slowly
• Eating small portions
• Avoiding fizzy drinks
• Postponing solid and dry foods if swallowing is difficult

Is difficulty swallowing normal after the operation?

In the first weeks, there may be temporary difficulty swallowing or a feeling that food passes slowly, due to swelling in the operated area. In most patients this lessens over time.

If you cannot swallow even liquids, have persistent vomiting, increasing difficulty swallowing or are unable to eat, you should contact the healthcare team.

Can there be wind and bloating?

After fundoplication, some patients may not be able to belch or vomit as easily as before. As a result, the following may occur:

• Bloating of the abdomen
• Increased wind
• Feeling full early
• Discomfort after meals

This can be called “gas-bloat syndrome”.

Avoiding fizzy drinks, eating slowly, not chewing gum and reducing air swallowing can help. In most patients the complaints lessen over time, but in some people they may continue for a long time.

Can reflux come back after the operation?

Reflux surgery can provide long-term control, but no method guarantees a definite result for life.

Over time, complaints may reappear because of:

• Recurrence of the hernia
• Loosening or slipping of the fundoplication
• Weight gain
• New oesophageal movement problems

The return of burning after surgery does not always mean that reflux has developed again. Endoscopy and reflux tests may be needed before medication is restarted or a second operation is planned.

When can you return to work?

In most patients, a return to desk work may be possible within about 1–2 weeks. Heavy lifting or physically demanding work may require a longer time.

A personal plan should be prepared taking into account the patient’s job, the size of the hernia and the extent of the operation.

1. Desai M, Yadlapati R, Gyawali CP, et al. American Society for Gastrointestinal Endoscopy Guideline on the Diagnosis and Management of Gastroesophageal Reflux Disease: Summary and Recommendations. Gastrointestinal Endoscopy. 2025. https://pubmed.ncbi.nlm.nih.gov/39692638/
2. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. American Journal of Gastroenterology. 2022;117(1):27–56. https://pmc.ncbi.nlm.nih.gov/articles/PMC8754510/
3. Gyawali CP, Yadlapati R, Fass R, et al. Updates to the Modern Diagnosis of GERD: Lyon Consensus 2.0. Gut. 2024;73(2):361–371. https://pmc.ncbi.nlm.nih.gov/articles/PMC10846564/
4. Yadlapati R, Gyawali CP, Pandolfino JE. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of Gastroesophageal Reflux Disease. Clinical Gastroenterology and Hepatology. 2022;20(5):984–994.e1. https://pmc.ncbi.nlm.nih.gov/articles/PMC9838103/
5. Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022;162(4):1334–1342. https://pubmed.ncbi.nlm.nih.gov/35183361/
6. Slater BJ, Dirks RC, McKinley SK, et al. SAGES Guidelines for the Surgical Treatment of Gastroesophageal Reflux Disease. Surgical Endoscopy. 2021;35:4903–4917. https://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-gastroesophageal-reflux-gerd/