Clinical guidelines for gastroesophageal reflux disease: diagnosis, treatment, and monitoring

Gastroesophageal reflux disease (GERD) is a condition in which stomach contents reflux into the esophagus, causing unpleasant symptoms or complications. In clinical practice, the most commonly reported symptoms include heartburn, acid or bitter regurgitation, pain or burning behind the breastbone, a sour taste in the mouth, sleep disturbances due to nocturnal reflux, as well as complications such as reflux esophagitis, esophageal stricture, and Barrett's esophagus. [1]

Current guidelines emphasize that gastroesophageal reflux disease is not always confirmed by complaints alone. Typical symptoms help initiate treatment, but in cases of atypical manifestations, lack of response to therapy, alarming signs, or before surgical treatment, objective confirmation of reflux is required through endoscopy and functional studies of the esophagus. [2]

A key principle of the latest guidelines is not to treat all patients the same. One person's heartburn may resolve quickly after a short course of a proton pump inhibitor, another has erosive esophagitis, another has functional heartburn without pathological reflux, and a fourth has severe regurgitation due to a hiatal hernia. Therefore, treatment should be based on the disease phenotype, not just the word "reflux" itself. [3]

In its 2022 guidelines, the American College of Gastroenterology recommends starting with an 8-week trial of a proton pump inhibitor once daily before meals for patients with classic heartburn and regurgitation symptoms without warning signs. If symptoms respond to treatment, a subsequent attempt is typically made to reduce the dose, switch to the minimum effective regimen, or discontinue the drug in uncomplicated patients. [4]

The 2023 Lyon Consensus 2.0 clarified current diagnostics: significant erosive esophagitis, a long segment of Barrett's esophagus, peptic stricture, and abnormal acid exposure time during reflux monitoring are considered reliable signs of gastroesophageal reflux disease. This is important because some patients have symptoms similar to reflux, but there is no true pathological acid reflux. [5]

Clinical task	What do modern guidelines recommend?	Practical meaning
Typical heartburn without warning signs	Proton pump inhibitor trial	Quick start of treatment without unnecessary research
Dysphagia, weight loss, bleeding, anemia, vomiting	Esophagogastroduodenoscopy	Exclusion of tumor, stricture, and severe esophagitis
No response to treatment	Check the correctness of the intake and clarify the diagnosis	Do not increase therapy blindly
Suspected functional heartburn	Daily reflux monitoring	Distinguishing reflux from esophageal hypersensitivity
Planning the operation	Objective confirmation of reflux and motility assessment	Reduce the risk of unsuccessful surgery
Long-term therapy	Minimum effective dose for a proven indication	Balance of benefits and safety

Source for table: Key points are consistent with the American College of Gastroenterology guidelines, the American Gastroenterological Association update, and the Lyon Consensus 2.0. [6]

When a diagnosis can be assumed clinically and when research is needed

If a patient presents with typical heartburn and regurgitation without any warning signs, clinical guidelines recommend empirical treatment with a proton pump inhibitor. This does not necessarily establish the diagnosis: this approach is a reasonable starting point, as typical symptoms are often associated with reflux and respond well to acid suppression. [7]

Warning signs change tactics. Difficulty swallowing, pain when swallowing, unintentional weight loss, gastrointestinal bleeding, iron deficiency anemia, frequent vomiting, or suspected complications require esophagogastroduodenoscopy rather than prolonged trial treatment without visual assessment of the mucosa. [8]

Esophagogastroduodenoscopy is also necessary if complicated disease is suspected, such as severe erosive esophagitis, esophageal stricture, Barrett's esophagus, ulcerative lesion, or tumor. During endoscopy, the physician evaluates the mucosa of the esophagus, stomach, and duodenum, and, if necessary, takes a biopsy. [9]

If endoscopy doesn't reveal convincing signs of reflux disease but symptoms persist, the next step may be outpatient reflux monitoring. This helps determine whether the symptoms are truly due to acid or mildly acidic reflux, or whether they are due to functional heartburn, esophageal hypersensitivity, or another cause. [10]

Before antireflux surgery or endoscopic antireflux intervention, objective confirmation of reflux is especially important. Surgery is more effective in patients with a proven pathological reflux load, but in patients with functional heartburn without reflux, surgical strengthening of the barrier between the stomach and esophagus may not eliminate symptoms. [11]

Situation	Recommended action	Why is this important?
Heartburn and regurgitation without warning signs	Proton pump inhibitor trial	Rapid and rational initiation of therapy
Dysphagia	Urgent endoscopic evaluation	Exclusion of stricture, tumor, and severe inflammation
Anemia or bleeding	Esophagogastroduodenoscopy	Finding the source of blood loss
No response to treatment	Intake check, endoscopy or reflux monitoring	Clarifying the diagnosis
Atypical symptoms	Don't rely on trial therapy alone	Cough, laryngitis and chest pain often have other causes.
Operation plan	Reflux monitoring and motility assessment	Confirmation of indications and reduction of the risk of complications

Source for the table: indications for endoscopy and functional diagnostics are reflected in the recommendations of the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy. [12]

Non-drug recommendations

Lifestyle modifications do not replace drug therapy for severe esophagitis or complications, but they can help reduce symptoms and decrease the need for medications in some patients. The most proven measures include weight loss if overweight, avoiding late meals, elevating the head of the bed if nocturnal symptoms occur, and avoiding eating several hours before bedtime. [13]

Weight loss is particularly important because abdominal obesity increases intra-abdominal pressure and increases reflux of stomach contents into the esophagus. In overweight patients, even moderate weight loss can reduce the frequency of heartburn and regurgitation, especially when combined with regular physical activity and reducing evening overeating. [14]

The recommendation to "eliminate all irritating foods" is outdated as a universal advice. A modern approach is more precise: patients are asked to identify personal triggers, such as fatty foods, chocolate, mint, coffee, alcohol, spicy foods, acidic drinks, or large portions, but not to ban the entire list outright if a specific food doesn't cause symptoms. [15]

A late dinner is a common cause of nighttime heartburn. Going to bed soon after eating makes it easier for stomach contents to enter the esophagus, so a practical recommendation is to avoid eating 2-3 hours before bed, reduce the size of your evening meal, and avoid fatty foods in the evening, as they stay in the stomach longer. [16]

For nighttime symptoms, elevating the head of the bed, rather than just using a high pillow, is helpful. A high pillow flexes the neck and torso but does not always reduce reflux; it is more logical to elevate the upper body or use a wedge pillow to reduce reflux when lying down. [17]

Measure	Who is it especially useful for?	Comment
Weight loss	Overweight patients	One of the most proven non-drug measures
Do not eat 2-3 hours before bedtime	Nocturnal heartburn and regurgitation	Especially important for late dinners
Raising the head of the bed	Nighttime symptoms	Better than just a high pillow
Individual trigger exclusion	Symptoms after specific foods	There is no need for a complete ban on all products for all patients.
Smaller portions	Symptoms after overeating	Reduces gastric distension
Limiting alcohol	Symptoms after alcohol and nighttime reflux	Especially important when combined with late meals
Quitting smoking	General vascular and digestive prophylaxis	May reduce reflux and lower overall disease risk

Source for table: Non-drug recommendations are based on the American College of Gastroenterology guidelines and the American Gastroenterological Association's personalized approach.[18]

First-line drug treatment

Proton pump inhibitors remain the mainstay of treatment for typical gastroesophageal reflux disease because they suppress acidity more strongly than H2-histamine receptor blockers and are more effective in healing erosive esophagitis. The drug is typically taken 30-60 minutes before meals, most often before breakfast, because this better matches the activity of proton pumps in the stomach. [19]

For classic symptoms without alarming signs, the standard initial treatment is 8 weeks of a proton pump inhibitor once daily. If symptoms resolve completely and there is no endoscopically severe esophagitis or Barrett's esophagus, recommendations suggest attempting to discontinue therapy or switch to the minimum effective regimen. [20]

If symptoms persist, the first step should not be to automatically switch to the "strongest" medication, but to check that you are taking it correctly. A common mistake is to take a proton pump inhibitor after meals or before bed for daytime heartburn; in such situations, the effect may be weaker than expected, and the medication may seem "not working." [21]

Antacids and alginates can be used for rapid relief of episodic symptoms, especially after meals. They are not a substitute for proton pump inhibitors in erosive esophagitis, but may be useful as an adjunct for occasional heartburn, postprandial regurgitation, or during a reduction in the dose of the main therapy. [22]

H2-histamine receptor antagonists may be helpful for mild or nocturnal symptoms, but with long-term regular use, their effectiveness may diminish. Therefore, they are more often considered as an adjunctive or alternative treatment option in selected patients, rather than as the primary treatment for severe erosive esophagitis. [23]

Treatment group	When is it applied?	Important notes
Proton pump inhibitors	Primary therapy for typical symptoms and erosive esophagitis	Usually taken 30-60 minutes before meals
Antacids	Fast, short-term relief	Severe esophagitis does not heal
Alginates	Post-eating symptoms and regurgitation	Create a mechanical barrier over the stomach contents
H2-histamine receptor blockers	Mild or nocturnal symptoms in some patients	With continuous use, the effect may decrease.
Prokinetics	Only for special indications	Not prescribed to all patients with reflux
Sucralfate	Limited role outside of pregnancy and certain situations	Not standard therapy for most patients

Source for table: drug approaches are consistent with recommendations of the American College of Gastroenterology, NICE, and the American Gastroenterological Association. [24]

What to do if treatment doesn't help

If symptoms persist while taking a proton pump inhibitor, it's important to first confirm whether the medication is being taken correctly. The doctor will review the timing, regularity, dosage, relationship of symptoms with food and sleep, the presence of regurgitation, chest pain, dysphagia, warning signs, and medications that may worsen reflux or damage the esophagus. [25]

If a partial response is observed, the doctor may temporarily increase the dose to two doses per day, usually before breakfast and before dinner. However, if symptoms persist despite proper therapy, current guidelines advise against indefinitely increasing acid suppression, but rather confirm the diagnosis and determine the mechanism of the symptoms. [26]

If gastroesophageal reflux disease has not previously been objectively proven, reflux monitoring is usually performed without a proton pump inhibitor. This helps determine whether pathological esophageal acid exposure exists under natural conditions, without the need for acid suppression medication. [27]

If the condition has already been proven, such as severe esophagitis or Barrett's esophagus, but symptoms persist despite therapy, monitoring can be performed during treatment. The goal then is different: to determine whether pathological reflux persists despite medication, whether the symptoms are related to non-acid reflux, or whether the cause of the symptoms is not reflux-related. [28]

An important diagnosis in the absence of a response is functional heartburn. This involves a burning sensation similar to reflux, but there are no objective signs of pathological reflux. In this situation, increasing the dose of the proton pump inhibitor is usually ineffective, and treatment may include explaining the diagnosis, addressing anxiety, pain neuromodulators, and behavioral interventions. [29]

Problem	Possible cause	Recommended step
Symptoms persist	Incorrect time of taking the drug	Take 30-60 minutes before meals
Partial answer	Insufficient acid suppression	Consider taking it twice daily for a limited period.
There is no objective diagnosis	Symptoms may not be due to reflux	Monitoring reflux without therapy
Proven disease, but symptoms are under treatment	Acid, slightly acidic, or non-acid reflux	pH-impedancemetry during treatment
The main complaint is regurgitation.	Mechanical barrier defect or hernia	Assess anatomy and surgical options
All tests are normal	Functional heartburn or hypersensitivity	Do not blindly increase acid suppression

Source for the table: The management of refractory symptoms is based on the personalized approach of the American Gastroenterological Association, the guidelines of the American College of Gastroenterology, and the Lyon Consensus 2.0. [30]

Endoscopy, pH-impedancemetry and manometry

Esophagogastroduodenoscopy best reveals mucosal damage: erosive esophagitis, ulcers, strictures, Barrett's esophagus, and tumor changes. However, a normal endoscopy does not rule out gastroesophageal reflux disease, as some patients experience symptoms associated with pathological reflux without visible erosions. [31]

The Lyon Consensus 2.0 clarified that erosive esophagitis grade B, C, or D according to the Los Angeles classification, a long segment of Barrett's esophagus, and peptic stricture are compelling evidence of gastroesophageal reflux disease. However, minimal mucosal changes are not always reliable enough, so when in doubt, functional tests are needed. [32]

Ambulatory pH monitoring, or pH-impedance monitoring, measures how long the esophagus is exposed to acid and whether symptoms coincide with reflux episodes. pH-impedance monitoring can also detect weakly acidic and non-acidic reflux, which is particularly useful in patients who continue to complain of symptoms while taking proton pump inhibitors. [33]

Esophageal manometry alone does not diagnose gastroesophageal reflux disease, but it helps assess esophageal motility. This is especially important before antireflux surgery, as significant motility impairments can alter the choice of intervention and reduce the risk of postoperative dysphagia. [34]

The American Society of Gastrointestinal Endoscopy, in its 2025 guidelines, emphasizes the need for careful endoscopic assessment and photographic documentation of objective signs of reflux disease, including landmarks of the esophagogastric junction and the state of the antireflux barrier. This makes the endoscopy findings more useful for subsequent management. [35]

Method	What does it show?	When especially needed
Esophagogastroduodenoscopy	Esophagitis, stricture, Barrett's esophagus, tumor changes	Alarming symptoms, complications, lack of response
Biopsy	Microscopic changes in the mucosa	Suspected Barrett's esophagus, eosinophilic esophagitis, or other disease
Daily pH monitoring	Acid exposure of the esophagus	Confirmation of diagnosis with normal endoscopy
Daily pH impedancemetry	Acid, slightly acidic and non-acid reflux	Symptoms during therapy
Esophageal manometry	Esophageal motility	Before surgery and if a motor disorder is suspected
Barium X-ray	Anatomy, large hernia, strictures	It is not the primary test for diagnosing reflux.

Source for table: The diagnostic role of endoscopy, reflux monitoring, and manometry is described in the American College of Gastroenterology guidelines, the Lyon Consensus 2.0, and the American Society of Gastrointestinal Endoscopy guidelines. [36]

Long-term therapy and discontinuation of proton pump inhibitors

Long-term treatment with proton pump inhibitors is not justified for all patients. It is usually necessary in cases of severe erosive esophagitis, Barrett's esophagus, peptic stricture, a high risk of recurrent complications, or symptoms that recur after discontinuation and significantly impair quality of life. [37]

In its update on proton pump inhibitor discontinuation, the American Gastroenterological Association recommends regularly re-evaluating the indications for long-term use. If the patient does not have a compelling chronic indication, the physician may suggest a dose reduction, switching to on-demand dosing, or discontinuation with observation. [38]

It is important not to discontinue a proton pump inhibitor simply because of general fear of potential side effects. Discontinuation guidelines emphasize that the decision should be based on the absence of an indication, not just theoretical risks; in patients with proven complications, the benefits of long-term therapy may outweigh the potential risks. [39]

After discontinuing the medication, a temporary "rebound" of acid secretion may occur, with heartburn intensifying for several days or weeks. Therefore, some patients find it more convenient to gradually reduce the dose, use antacids, alginates, or H2-histamine receptor blockers for short periods, and strictly adhere to non-drug measures. [40]

If symptoms recur quickly and persistently, this does not mean the patient is "dependent" on the medication. It may indicate that gastroesophageal reflux disease requires maintenance therapy; in this case, the physician's task is to select the minimum effective dose and ensure that the diagnosis and indications for long-term treatment are correct. [41]

Situation	Tactics	Comment
Severe erosive esophagitis	Long-term maintenance therapy is often needed.	High risk of relapse
Barrett's esophagus	Long-term therapy is often justified.	The risk of complications is taken into account
Symptoms went away after 8 weeks	Try withdrawal or a minimal dose	If there are no complications
Symptoms are rare	Admission on request	Not suitable for everyone
There are no indications for long-term therapy	Consider cancellation	A monitoring plan is desirable
Relapse after discontinuation	Return to the minimum effective scheme	It is important to confirm the diagnosis if in doubt.

Source for table: The approach to long-term therapy and discontinuation of proton pump inhibitors is based on the recommendations of the American College of Gastroenterology and the American Gastroenterological Association. [42]

Complications and Barrett's esophagus

Complicated gastroesophageal reflux disease includes severe erosive esophagitis, ulcers, bleeding, esophageal stricture, Barrett's esophagus, and, less commonly, esophageal adenocarcinoma. The presence of complications changes the management: the patient usually requires endoscopic evaluation, longer-term treatment, and observation depending on the changes found. [43]

Barrett's esophagus is a condition in which the normal lining of the lower esophagus is replaced by specialized intestinal metaplasia. It is considered a complication of chronic reflux and a risk factor for esophageal adenocarcinoma, although the absolute risk of cancer in many patients remains low and depends on the length of the segment, the presence of dysplasia, and other factors. [44]

In its 2022 guideline update, the American College of Gastroenterology recommends considering screening for Barrett's esophagus in patients with chronic reflux symptoms and several risk factors. These factors include male gender, age over 50, white race, obesity, smoking, and a family history of Barrett's esophagus or esophageal adenocarcinoma.[45]

If Barrett's esophagus is diagnosed, the treatment strategy depends on the presence of dysplasia. In the absence of dysplasia, endoscopic surveillance is typically performed at regular intervals, while if low- or high-grade dysplasia is confirmed, endoscopic methods for eradication of the altered mucosa may be considered in a specialized center. [46]

It is important for patients to understand that the presence of heartburn does not necessarily mean they have Barrett's esophagus, and the absence of heartburn does not always rule it out. Therefore, the decision to screen is made not based on the severity of symptoms, but rather on a combination of chronic reflux, risk factors, and the physician's clinical assessment. [47]

Complication	How does it manifest itself?	What is usually required
Erosive esophagitis	Heartburn, pain, sometimes bleeding	Proton pump inhibitor and severity assessment
Esophageal stricture	Difficulty swallowing	Endoscopy, treatment of inflammation, sometimes dilation
Esophageal ulcer	Pain, bleeding, anemia	Endoscopic diagnosis and treatment
Barrett's esophagus	Often asymptomatic or associated with chronic reflux	Biopsy and observation
Dysplasia in Barrett's esophagus	Precancerous change	Confirmation by an expert pathologist and endoscopic treatment
Esophageal adenocarcinoma	Dysphagia, weight loss, anemia, late symptoms	Urgent specialized diagnostics

Source for table: Complications and approach to Barrett's esophagus are described in the American College of Gastroenterology guidelines on gastroesophageal reflux disease and Barrett's esophagus.[48]

Surgical and endoscopic treatment

Antireflux surgery may be considered in patients with proven gastroesophageal reflux disease, particularly if there is significant regurgitation, a large hiatal hernia, a need for long-term therapy, or an unwillingness to take medications with objectively confirmed reflux. The key is to demonstrate that the symptoms are truly related to reflux. [49]

The most well-known surgical method is fundoplication, which involves forming a cuff around the lower esophagus from the upper stomach, strengthening the antireflux barrier. This surgery can be effective, but it requires careful patient selection, as it can lead to dysphagia, gas bloating, belching, and recurrence of symptoms. [50]

Endoscopy, reflux monitoring, and esophageal manometry are usually required before surgery. These tests help confirm the diagnosis, evaluate the hernia, rule out other conditions, and determine whether the esophagus will be able to move food normally after strengthening the antireflux barrier. [51]

Endoscopic antireflux techniques occupy a more limited place. The American Society of Gastrointestinal Endoscopy's 2025 guidelines discuss endoscopic strategies, including transoral incisionless fundoplication, radiofrequency techniques, and the combination of endoscopic fundoplication with hernia repair in selected patients. [52]

Surgical or endoscopic treatment should not be used as a way to "check the diagnosis." If reflux is not proven and symptoms are caused by functional heartburn, esophageal hypersensitivity, eosinophilic esophagitis, dysmotility, or a cardiopulmonary cause, intervention may not help and may even worsen quality of life. [53]

Method	Who might it be suitable for?	What is important before choosing
Laparoscopic fundoplication	Proven reflux, regurgitation, hernia	Endoscopy, reflux monitoring, manometry
Magnetic enhancement of the lower esophageal sphincter	Selected patients with proven reflux	Assessment of anatomy and motor skills
Transoral incisionless fundoplication	Selected patients without a large hernia	Strict indications are needed
Correction of esophageal hernia of the diaphragm	Significant hernia and proven reflux	Assessing hernia size and symptoms
Radiofrequency endoscopic methods	Limited indications	Effect and availability depend on selection
Refusal to interfere	No objective reflux	Another cause of the symptoms needs to be looked for.

Source for table: Surgical and endoscopic approaches require proven gastroesophageal reflux disease and proper patient selection. [54]

Frequently asked questions

Can gastroesophageal reflux disease be diagnosed based on heartburn alone? For typical heartburn and regurgitation without warning signs, a doctor may initiate a trial course of a proton pump inhibitor, but this is not always definitive proof of diagnosis. If symptoms are atypical, treatment is ineffective, or surgery is planned, objective testing is needed. [55]

When is an esophagogastroduodenoscopy absolutely necessary? It is necessary in cases of difficulty swallowing, pain when swallowing, weight loss, bleeding, anemia, frequent vomiting, suspected stricture, Barrett's esophagus, tumor, or failure to respond to proper treatment. [56]

What is the correct time to take a proton pump inhibitor? It is usually taken 30-60 minutes before meals, most commonly before breakfast; with a twice-daily regimen, it is taken before breakfast and before dinner. Incorrect timing is a common cause of apparent treatment failure. [57]

How long does a standard trial course of treatment last? For classic symptoms without warning signs, a standard trial course of proton pump inhibitor is usually 8 weeks. After a response to treatment in uncomplicated patients, discontinuation or the lowest effective dose is considered. [58]

Should everyone take proton pump inhibitors for life? No. Long-term therapy is needed for proven indications, such as severe erosive esophagitis, Barrett's esophagus, stricture, or persistent recurrence of symptoms after discontinuation. If there is no indication, treatment should be periodically reviewed. [59]

What should you do if the medication isn't helping? First, you need to check that you're taking it correctly, then confirm the diagnosis. In the absence of objectively proven disease, reflux monitoring without therapy may be necessary, and if the disease is already proven, pH-impedance monitoring may be necessary during treatment. [60]

Why can heartburn occur but reflux not? In some patients, symptoms are explained by functional heartburn or esophageal hypersensitivity, where normal or even physiological stimuli are perceived as pain or burning. In such cases, endless attempts at acid suppression are usually ineffective. [61]

What foods are prohibited for reflux disease? There is no universal ban for everyone. It's better to identify individual triggers: fatty foods, chocolate, mint, coffee, alcohol, spicy foods, acidic drinks, or large portions, if these are the ones that trigger symptoms in a particular person. [62]

When is surgery considered? Surgery is considered in cases of proven gastroesophageal reflux disease, particularly in cases of severe regurgitation, hiatal hernia, the need for long-term treatment, or the patient's desire to avoid lifelong medications with objectively confirmed reflux. [63]

What is the danger of Barrett's esophagus? Barrett's esophagus increases the risk of esophageal adenocarcinoma, but the risk depends on the segment's length and the presence of dysplasia. Therefore, when it is detected, panic is not necessary. Instead, a proper biopsy, assessment of dysplasia, and endoscopic observation or treatment as indicated are needed. [64]

Key points from experts

Philip O. Katz, MD, MACG, lead author of the 2022 American College of Gastroenterology guideline on gastroesophageal reflux disease, emphasizes a practical approach: typical symptoms without alarm features allow for a trial of therapy, but with alarm symptoms, refractoriness, or before intervention, an objective evaluation is needed. [65]

Rena Yadlapati, MD, MSHS, lead author of the 2022 American Gastroenterological Association expert update, promotes a personalized model for the management of gastroesophageal reflux disease. Her key idea: treatment should take into account the disease phenotype, the likelihood of true reflux, the mechanism of symptoms, and the results of objective tests. [66]

C. Prakash Gyawali, MD, professor of gastroenterology and one of the lead authors of the Lyon Consensus 2.0, emphasized evidence-based support for “actionable gastroesophageal reflux disease,” that is, reflux in which test results actually justify changing, intensifying, or personalizing treatment. [67]

Nicholas J. Shaheen, MD, MPH, lead author of the 2022 American College of Gastroenterology guideline update on Barrett's esophagus, emphasizes a risk-based approach to screening and surveillance. This means that endoscopic screening is not needed for all patients with heartburn, but rather for those with chronic reflux and additional risk factors. [68]

Mouen A. Khashab and Manikandan Desai et al., in the 2025 American Society of Gastrointestinal Endoscopy guidelines, reinforced the role of quality endoscopic assessment in reflux disease: the endoscopist should carefully describe objective signs, landmarks of the esophagogastric junction, and the status of the antireflux barrier. [69]

Laura E. Targownik, MD, lead author of the American Gastroenterological Association's update on proton pump inhibitor discontinuation, emphasizes the regular review of indications for long-term therapy. The practical takeaway: discontinuing the drug should be done when there is no indication, but not in patients who need it to prevent recurrence of complications. [70]

Result

Clinical guidelines for gastroesophageal reflux disease are based on three principles: first, assess the typicality of symptoms and warning signs, then prescribe appropriate treatment or examination, and, if therapy is ineffective, confirm the mechanism of symptoms with objective tests. This approach protects patients from both undertreated reflux and unnecessary, long-term medication use without a proven diagnosis. [71]

Proton pump inhibitors remain the mainstay of treatment for typical disease and erosive esophagitis, but they must be taken correctly, indications for long-term therapy must be reviewed, and the minimum effective regimen must be used if there are no complications. In severe esophagitis, Barrett's esophagus, stricture, or recurrent symptoms, maintenance therapy may be warranted. [72]

If symptoms persist, the modern tactic is not to endlessly increase acid suppression, but to clarify the diagnosis: endoscopy, pH-metry, pH-impedancemetry and manometry help to distinguish true reflux from functional heartburn, increased sensitivity of the esophagus, motor disorders and other diseases. [73]