Gastroesophageal reflux disease is treated by reducing the exposure of the esophagus to refluxate and protecting its mucosa. Four levers are used, often together: lifestyle change, acid suppression, drugs that act on the sphincter or on motility, and anti-reflux surgery for selected patients.
Lifestyle and symptom relief
Lifestyle measures are worth starting in every patient, but their effect is modest unless they address a specific driver. Weight reduction improves symptoms in patients who are overweight or obese, because excess abdominal fat raises intra-abdominal pressure and promotes reflux. Avoiding individual trigger foods and eating patterns, such as meals close to bedtime, can help some patients, and sodium alginate or antacids give temporary symptom relief while acid suppression takes effect.
Initial acid suppression
The cornerstone of medical treatment is suppression of gastric acid. A standard dose of a proton pump inhibitor (PPI) taken once daily for 4 to 8 weeks is the recommended initial treatment; PPIs achieve complete relief in about 70-80% of patients with erosive esophagitis and about 60% of patients with non-erosive disease. PPIs are more effective than histamine H2-receptor antagonists for both symptom control and mucosal healing. Potassium-competitive acid blockers (P-CABs), which suppress acid faster and more completely, are comparable to PPIs and are an alternative first-line choice.
A PPI works best when taken before a meal, so when symptoms persist the first step is to check adherence and timing before changing the drug.
When the standard dose is not enough
If symptoms persist on a standard dose, the dose can be doubled (standard dose twice daily), or the patient can be switched to a P-CAB or another PPI. Adding a prokinetic drug or a herbal preparation is a further option with weaker evidence.
A patient whose symptoms remain uncontrolled after at least 8 weeks of a standard dose is said to have PPI-refractory GERD. At that point the priority is to establish whether the symptoms are truly caused by reflux rather than to keep escalating blindly; the differential includes an incorrect diagnosis, insufficient acid suppression, weakly acidic or non-acidic reflux, and a concomitant functional disorder. Reflux monitoring and manometry are used to sort these out.
Maintenance therapy
GERD tends to relapse after treatment is stopped, so many patients need ongoing therapy. For non-erosive reflux disease or mild erosive reflux disease, on-demand or minimal-dose PPI is comparable to continuous daily dosing. For severe erosive esophagitis, continuous maintenance is needed to prevent relapse and the complications of chronic injury.
Anti-reflux surgery
Anti-reflux surgery, usually laparoscopic fundoplication, is an option for patients with proven GERD whose symptoms are not controlled by medication, or who prefer not to take long-term drugs. It re-creates a barrier by wrapping the stomach around the lower esophagus. Because the wrap depends on the esophagus being able to push food through, reflux monitoring is used to confirm pathological reflux and manometry to exclude a motility disorder before surgery is offered. Endoscopic anti-reflux procedures exist but are less established.