A journey through GORD, PPIs, gastroscopes, pH probes and, occasionally, some creative rearrangement of the stomach
Disclaimer
This article reflects my personal professional interests and interpretation of published evidence. It does not represent my employer, colleagues or the NMC, and no patient-identifiable information is included. It is intended for education rather than individual medical advice. Symptoms—particularly difficulty swallowing, gastrointestinal bleeding, unexplained weight loss, persistent vomiting or significant chest pain—require appropriate clinical assessment. Clinical decisions should always be individualised by the treating healthcare team.
Working in Upper Gastrointestinal surgery means that I get asked quite a lot of questions about reflux.
“Why do I keep getting heartburn?”
“Should I be taking omeprazole forever?”
“Why do I need a camera down my throat?”
And, occasionally, the rather optimistic:
“Can you just fix the valve?”
Unfortunately, the gastro-oesophageal junction was not designed by a plumber, so matters are slightly more complicated.
Gastro-oesophageal reflux disease—GORD in the UK and GERD across the Atlantic—is one of the commonest disorders affecting the upper gastrointestinal tract. Importantly, reflux itself is physiological. Most people reflux small amounts of gastric contents occasionally. Disease develops when reflux causes troublesome symptoms or complications such as oesophagitis, peptic stricture or Barrett’s oesophagus (Gyawali et al., 2024).
Why does reflux happen?
At the bottom of the oesophagus sits the lower oesophageal sphincter, supported anatomically by the diaphragmatic crura. Together they form an anti-reflux barrier. Reflux becomes more likely when this barrier fails, particularly through transient lower oesophageal sphincter relaxations, reduced sphincter pressure or anatomical disruption from a hiatus hernia.
Obesity increases intra-abdominal pressure and is strongly associated with reflux, while large meals, lying down shortly after eating and certain foods or alcohol can exacerbate symptoms in susceptible individuals. Pregnancy and medications that influence smooth-muscle tone may also contribute. However, reflux should not simply be reduced to somebody having eaten the wrong dinner: its pathophysiology combines anatomy, motility, gastric pressure, oesophageal clearance and mucosal sensitivity (Katz et al., 2022).
The classical symptoms are retrosternal burning—heartburn—and regurgitation. Patients may also describe chest discomfort, nocturnal symptoms or sour fluid entering the mouth. Cough, throat clearing and laryngeal symptoms can occur, although attributing these automatically to reflux is hazardous because their differential diagnosis is broad (Katz et al., 2022).
First stop: primary care
Assuming obtaining a GP appointment has not itself become the most challenging component of the diagnostic pathway, primary care remains where most reflux is appropriately managed.
For uncomplicated reflux-type symptoms NICE recommends an empirical proton-pump inhibitor (PPI) trial. Lifestyle interventions should accompany this: weight reduction where appropriate, avoiding meals close to bedtime and identifying individual dietary triggers rather than issuing everybody with a joyless universal list of forbidden foods (NICE, 2014).
PPIs—including omeprazole, lansoprazole, esomeprazole and pantoprazole—reduce gastric acid secretion by inhibiting the gastric parietal-cell H+/K+-ATPase. Crucially, they do not stop reflux occurring. They make the material being refluxed less acidic and therefore less injurious.
NICE recommends full-dose PPI therapy for four to eight weeks for GORD, subsequently reducing treatment to the lowest dose that adequately controls recurrent symptoms. H2-receptor antagonists can be considered where PPI response is inadequate, while alginates and antacids remain useful for intermittent symptomatic relief (NICE, 2014).
Before declaring a PPI ineffective, however, it is worth checking how it is actually being taken. Timing, adherence and adequate dosing matter. Simply escalating medication indefinitely without reconsidering the diagnosis risks treating symptoms that may not be reflux-related at all (Katz et al., 2022).
Alarm features change the pathway. Dysphagia warrants suspected-cancer-pathway referral under current NICE guidance; patients aged 55 or over with weight loss plus reflux, dyspepsia or upper abdominal pain also meet referral criteria. Gastrointestinal bleeding and other concerning features similarly require appropriate investigation rather than another repeat prescription (NICE, 2025).
When tablets are not enough
Persistent symptoms despite appropriately optimised treatment may lead to referral to gastroenterology or Upper GI surgery.
This is where reflux becomes particularly interesting because symptoms alone cease to be sufficient. Modern reflux assessment attempts to answer three separate questions:
Is there anatomical disease? Is pathological reflux actually occurring? And does the oesophagus function normally enough for the proposed treatment?
Gastroscopy
Oesophagogastroduodenoscopy—or gastroscopy—allows direct assessment of the oesophagus, gastro-oesophageal junction, stomach and duodenum. It can identify erosive oesophagitis, Barrett’s oesophagus, strictures, malignancy and hiatus hernia.
The Lyon Consensus 2.0 regards Los Angeles grade B, C or D oesophagitis, biopsy-proven Barrett’s oesophagus and peptic stricture as conclusive evidence supporting GORD (Gyawali et al., 2024). A normal gastroscopy, however, absolutely does not exclude reflux. Many symptomatic patients have non-erosive reflux disease.
Contrast swallow
A barium or water-soluble contrast swallow provides dynamic anatomical information. It is particularly useful when assessing a hiatus hernia, oesophageal emptying, strictures, postoperative anatomy or suspected anatomical obstruction.
It does not replace endoscopy or physiological reflux testing. Rather, it answers a different question: what happens mechanically when the patient swallows?
High-resolution manometry
Manometry sounds medieval but is rather sophisticated.
A pressure-sensing catheter measures oesophageal peristalsis and lower oesophageal sphincter function during repeated swallows. Before anti-reflux surgery, its most important role is excluding major motility disorders—particularly achalasia—which can masquerade as reflux but require entirely different treatment.
The British Society of Gastroenterology recommends oesophageal manometry before anti-reflux surgery for precisely this reason (Trudgill et al., 2019).
pH and impedance monitoring
Ambulatory reflux monitoring asks the crucial question: is reflux actually causing the problem?
Traditional pH monitoring quantifies oesophageal acid exposure. Combined pH-impedance testing additionally detects weakly acidic and non-acid reflux by measuring movement of liquid and gas through the oesophagus.
This distinction becomes particularly useful in patients whose symptoms continue despite acid suppression.
Modern consensus separates unproven GORD from previously proven disease. Where the diagnosis remains uncertain, reflux monitoring is generally performed off acid suppression; where GORD is already objectively established but symptoms continue despite treatment, pH-impedance testing on optimised therapy can investigate persistent reflux mechanisms (Gyawali et al., 2024).
The principle is simple: before performing an irreversible operation for reflux, it is sensible to demonstrate that reflux actually exists.
And then comes surgery
When objective reflux is demonstrated and symptoms remain troublesome despite appropriate medical therapy—or when significant anatomical disease exists—anti-reflux surgery may be considered.
This is not merely what happens when omeprazole “stops working”. Patient selection is fundamental.
Fundoplication: rebuilding the barrier
Fundoplication uses the gastric fundus to reinforce the gastro-oesophageal junction, usually alongside repair of an associated hiatal defect.
A Nissen fundoplication creates a complete 360-degree wrap around the distal oesophagus. It produces a strong anti-reflux barrier but can be associated with postoperative dysphagia, gas-bloat and reduced ability to belch or vomit.
Partial fundoplications aim to balance reflux control against these functional consequences. A Toupet typically creates a posterior 270-degree wrap, while other partial configurations are also used.
Current SAGES guidance supports both complete and partial fundoplication, with procedural choice influenced by anatomy, symptoms, patient priorities and surgical expertise. Evidence suggests partial wraps may reduce dysphagia at the potential cost of differences in reflux control in selected patients (Slater et al., 2021).
Gastropexy: sometimes anatomy is the bigger problem
Gastropexy fixes the stomach within the abdomen and may form part of hiatus or paraoesophageal hernia surgery. Importantly, gastropexy alone should not be viewed as simply another version of fundoplication.
Its principal purpose is anatomical—reducing migration or volvulus risk—rather than constructing a circumferential anti-reflux barrier. In selected patients, particularly where extensive reconstruction carries disproportionate risk, gastropexy may therefore be useful. The exact operation depends considerably on hernia anatomy, physiology and patient fitness.
Reflux and obesity: where Roux-en-Y enters the conversation
Obesity creates a particular surgical problem. A fundoplication can reinforce the gastro-oesophageal junction, but it does not remove the underlying metabolic and pressure-related drivers associated with severe obesity.
For appropriately selected patients requiring metabolic surgery, Roux-en-Y gastric bypass (RYGB) can address both obesity and reflux.
RYGB creates a small proximal gastric pouch connected to the jejunum. This reduces acid-producing gastric volume, diverts bile and pancreatic secretions away from the oesophagus and produces substantial weight loss, thereby reducing intra-abdominal pressure.
Consequently, international guidance recognises RYGB as an important option for patients with obesity and significant GORD, although the choice between bypass and conventional anti-reflux surgery requires multidisciplinary assessment rather than assuming every patient with reflux and a raised BMI requires gastric bypass (Slater et al., 2021).
From heartburn to reconstruction
The reflux pathway therefore runs considerably further than:
Heartburn → omeprazole → stronger omeprazole → surgeon.
Most people never require surgery. Many achieve excellent control with lifestyle modification and appropriately used acid suppression.
For those who do not, the purpose of specialist investigation is not simply to accumulate increasingly elaborate tests. Gastroscopy examines mucosal disease and anatomy; contrast studies demonstrate structure and transit; manometry assesses oesophageal mechanics; and pH or impedance testing determines whether pathological reflux is genuinely present.
Only then should the conversation turn seriously towards reconstruction.
Because ultimately successful anti-reflux surgery is not about operating on heartburn.
It is about identifying the correct physiological problem, in the correct patient, and selecting an operation that corrects that problem while creating as few new ones as possible.
Which, admittedly, is a slightly less catchy answer when somebody asks me whether we can “just fix the valve”.
References
Gyawali, C.P., Yadlapati, R., Fass, R. et al. (2024) ‘Updates to the modern diagnosis of GERD: Lyon consensus 2.0’, Gut, 73(2), pp. 361–371.
Katz, P.O., Dunbar, K.B., Schnoll-Sussman, F.H., Greer, K.B., Yadlapati, R. and Spechler, S.J. (2022) ‘ACG Clinical Guideline for the diagnosis and management of gastroesophageal reflux disease’, American Journal of Gastroenterology, 117(1), pp. 27–56. doi:10.14309/ajg.0000000000001538.
National Institute for Health and Care Excellence (NICE) (2014) Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184). London: NICE. Updated guidance accessed 2026.
National Institute for Health and Care Excellence (NICE) (2025) Suspected cancer: recognition and referral (NG12). London: NICE.
Slater, B.J., Dirks, R.C., McKinley, S.K. et al. (2021) ‘SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD)’, Surgical Endoscopy, 35(9), pp. 4903–4917. doi:10.1007/s00464-021-08625-5.
Trudgill, N.J., Sifrim, D., Sweis, R. et al. (2019) ‘British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring’, Gut, 68(10), pp. 1731–1750.
Leave a Reply