GERD: Chronic Acid Reflux

Where the esophagus meets the stomach there is a pressure zone formed by a ring of muscle and the surrounding diaphragm. Working correctly, it opens to let food pass and closes to keep stomach contents down.

In GERD that barrier fails. It may relax at the wrong times, sit too weakly, or be pulled out of position by a hiatal hernia. Acid is doing what acid always does. The difference is that it is reaching tissue not built to tolerate it.

That distinction shapes treatment. Acid suppressing medication reduces how damaging the refluxed material is. It does not restore a barrier that is not closing, and symptoms can return when it stops.

The familiar presentation is burning behind the breastbone, worse after meals, worse lying flat, sometimes with a sour taste. That version is easy to recognize.

Reflux can sometimes contribute to chronic cough, hoarseness, or throat clearing, but these symptoms have many causes and the link to reflux is frequently overstated. Acid suppressing medication often does not resolve them. Objective reflux testing matters before attributing throat symptoms to reflux or recommending an operation. Dental erosion and a sensation of a lump in the throat are described in the same way. Chest pain deserves a specific note: never assume chest pain is reflux until cardiac causes have been excluded.

Symptoms alone predict what is happening in the esophagus poorly. Two people with identical complaints can have entirely different findings, and the treatment that follows should differ accordingly.

Current consensus separates conclusive from inconclusive evidence of reflux. Conclusive findings include severe grades of esophagitis, biopsy proven Barrett's esophagus, a peptic stricture, or acid exposure time above six percent. Acid exposure below four percent is evidence against reflux. Between four and six percent is inconclusive and requires additional measures such as the number of reflux episodes, mean nocturnal baseline impedance, and how well symptoms line up with reflux events.

High resolution manometry may be recommended before an antireflux operation. It excludes achalasia and other major motility disorders and characterizes how the esophagus moves, which directly influences the choice of wrap. Findings are reported using the current Chicago Classification, version 4.0 from 2021.

Bravo is a small wireless capsule attached to the esophageal lining during endoscopy that records acid exposure for 48 to 96 hours, capturing more days of data than a traditional catheter study. A catheter-based pH-impedance study runs 24 hours and additionally measures non-acid and gaseous reflux, which makes it the test used while a patient is still on medication to evaluate refractory symptoms. Upper endoscopy inspects the lining directly and takes biopsies when indicated. Manometry measures the muscular function of the esophagus and is essential before considering any procedure that alters the valve. Imaging such as a barium study is added when anatomy needs clarifying.

Behavioral and dietary changes come first and genuinely help some people. Elevating the head of the bed, separating meals from sleep, and identifying personal triggers are generally low-cost and low-risk for many people, but recommendations should be individualized.

Acid suppressing medication is effective and appropriate for many. Long term use is a discussion to have with your physician.

When medication fails, when a hiatal hernia is driving the problem, when damage is present on endoscopy, or when someone does not want a lifetime of medication, procedural options are discussed. What is appropriate depends heavily on the manometry and pH findings, which is why testing comes before that conversation rather than after.

Reflux is treated here with the same seriousness as metabolic disease, and it is evaluated on its own terms. A surgical evaluation is reasonable when medication is not controlling symptoms, when it works but you do not want to take it indefinitely, when endoscopy has shown esophagitis or Barrett's changes, or when a hiatal hernia has been identified.

This page is educational information, not medical advice. What is right for you is decided in consultation, after a review of your history, your symptoms, and your testing.