Initial assessment
In the presence of typical reflux symptoms — namely heartburn and regurgitation — the first step is to characterize symptom pattern, duration and impact on quality of life, as well as to identify predisposing factors (e.g. overweight, late meals, alcohol, smoking, coffee, chocolate, citrus fruits, large meals) and medications that may worsen reflux (e.g. NSAIDs, calcium channel blockers, nitrates). Alarm features should also be actively sought, including dysphagia, odynophagia, unintentional weight loss, anaemia, gastrointestinal bleeding, persistent vomiting or family history of gastroesophageal malignancy, as these determine the need for early endoscopic evaluation.
When should endoscopy be performed?
Upper gastrointestinal endoscopy is indicated in the presence of alarm features, suspected complications (e.g. peptic stricture) or treatment failure after an adequate initial PPI regimen. In patients with typical symptoms without alarm features, it is acceptable to start a therapeutic trial with a PPI for 4–8 weeks before requesting endoscopy.
Therapeutic trial with PPI
In the empirical approach, a PPI is recommended once daily, taken 30–60 minutes before a meal, for 4–8 weeks. If the response is only partial, adherence, timing of intake and dosing should be reviewed, with optimization to PPI twice daily for 8 weeks. Lack of response despite this optimization defines suspected refractory GERD.
The role of functional assessment
When symptoms persist after treatment optimization and endoscopy does not show erosive oesophagitis, functional assessment may be indicated. pH-impedance monitoring quantifies acid and non-acid reflux and correlates reflux events with symptoms; oesophageal manometry is useful before considering endoscopic or surgical anti-reflux therapy, as it helps exclude major motility disorders.
Erosive oesophagitis
When endoscopy shows erosive oesophagitis, induction therapy with PPI twice daily for 8 weeks is recommended to promote healing and symptom control. After the induction phase, PPI should be maintained at the lowest effective dose that controls symptoms. Longer treatment courses may be required in peptic stricture or early relapse.
Barrett’s oesophagus
In Barrett’s oesophagus, endoscopic surveillance is based on segment length and the presence of dysplasia. In the absence of dysplasia, surveillance follows defined intervals; in the presence of low-grade or high-grade dysplasia, endoscopic therapies should be considered, particularly radiofrequency ablation.
Non-pharmacological treatment
Behavioural measures include weight loss, avoiding large and late meals, reducing alcohol and tobacco, moderating individually identified trigger foods and elevating the head of the bed in patients with nocturnal symptoms. These interventions are particularly useful in patients with obesity or postprandial symptoms.
Advanced options — documented refractory disease
In patients with objectively confirmed reflux and clinically relevant refractoriness, anti-reflux procedures may be considered. Laparoscopic fundoplication remains the reference procedure, although endoscopic options and selected devices may be appropriate in specific cases. The decision should be individualized and ideally discussed in a specialist setting.
Phenotypic differentiation
It is important to recognize that not all heartburn corresponds to GERD. pH-impedance monitoring can distinguish between NERD (non-erosive reflux disease), reflux hypersensitivity and functional heartburn, entities with different treatment responses and prognoses.
Maintenance and follow-up
After symptom control, PPI should be maintained at the lowest effective dose, with reassessment of adherence, lifestyle measures and the need for chronic therapy. In patients with Barrett’s oesophagus or complications, endoscopic follow-up should follow the intervals recommended in international guidelines.
