Management of gastro-oesophageal reflux disease

Definition and mechanism. GORD exists when reflux of gastric contents causes troublesome symptoms or complications. Mechanisms include transient lower oesophageal sphincter relaxations (the dominant mechanism), a hypotensive LOS, hiatus hernia, delayed gastric emptying and impaired oesophageal acid clearance.

Presentation in the elderly — the key examination point. Symptoms are milder or atypical but mucosal injury is more severe: erosive oesophagitis, peptic stricture and Barrett's oesophagus are all commoner, while heartburn is reported less often because of diminished oesophageal sensitivity. Presentations include dysphagia, vomiting, weight loss, anaemia, chest pain, chronic cough, hoarseness and aspiration pneumonia.

Aggravating factors. Obesity, hiatus hernia, smoking, alcohol, large or late meals and recumbency; and drugs that reduce LOS pressure or injure the mucosa — calcium channel blockers, nitrates, anticholinergics, theophylline, benzodiazepines, bisphosphonates, potassium chloride, doxycycline and NSAIDs. Reviewing the drug chart is a therapeutic act in the elderly.

Alarm features requiring endoscopy. Dysphagia, odynophagia, weight loss, persistent vomiting, anaemia, gastrointestinal bleeding, and new-onset symptoms in a patient over 60. The threshold for endoscopy must be lower than in the young, because empirical acid suppression may mask malignancy.

Investigations. Upper GI endoscopy graded by the Los Angeles classification (A–D) with biopsy for Barrett's oesophagus; ambulatory 24-hour pH or pH-impedance monitoring performed off PPI is the gold standard for confirming pathological acid exposure in non-erosive disease; high-resolution manometry before anti-reflux surgery and to exclude achalasia; and barium swallow for strictures and large hernias.

Lifestyle measures. Weight reduction, elevation of the head end of the bed by 6–8 inches, avoiding meals within 3 hours of lying down, left lateral sleeping position, smoking and alcohol cessation, and avoidance of individual trigger foods. These carry no drug risk and are especially valuable in the elderly.

Pharmacological therapy. Proton pump inhibitors are the drugs of choice, given once daily 30–60 minutes before breakfast for 8 weeks; they are clearly superior to H receptor antagonists for healing oesophagitis. No 2 dose reduction is required for age, but step down to the lowest effective dose or on-demand therapy after healing. Antacids and alginates provide symptomatic relief, an H blocker may be added at night for nocturnal breakthrough, 2 and prokinetics have no established role.

Long-term PPI safety in older adults. A causal relationship is likely for acute interstitial nephritis, benign fundic gland polyps, enteric infections including C. difficile, vitamin B deficiency and 12 hypomagnesaemia. Associations with fracture, pneumonia, dementia and progression of CKD are not supported by strong evidence and are heavily confounded. Review the indication periodically and deprescribe where possible; the clopidogrel interaction is clinically meaningful essentially only for omeprazole.

Complications and their management. Erosive oesophagitis; peptic stricture — endoscopic dilatation plus long-term PPI; bleeding; Barrett's oesophagus requiring surveillance endoscopy, with endoscopic eradication therapy for high-grade dysplasia; oesophageal adenocarcinoma; and extra-oesophageal disease (asthma, chronic cough, laryngitis, dental erosion, aspiration).

Refractory disease and surgery. First confirm adherence and correct dosing timing, then optimise to twice-daily PPI, and re-evaluate with pH-impedance testing to identify functional heartburn or reflux hypersensitivity (treated with low-dose tricyclics or SSRIs, used cautiously in the elderly). Laparoscopic fundoplication gives outcomes and complication rates in patients over 70 comparable to the young, but long-term medical therapy is usually more cost-effective given remaining life expectancy; patients with ineffective oesophageal motility are at risk of post-operative dysphagia. Endoscopic anti-reflux procedures remain investigational.

AGA Clinical Practice Update on potassium-competitive acid blockers (Gastroenterology 2024;167:1228) — vonoprazan is superior to PPIs for healing and maintaining healing of severe (LA grade C/D) erosive oesophagitis and for H. pylori eradication, and is now FDA-approved for both erosive and non-erosive GERD. However, the update advises that P-CABs should not be used first-line for mild (LA grade A/B) oesophagitis, nor for peptic ulcer treatment or prophylaxis, so their role is targeted rather than universal.

ASGE Clinical Practice Guideline on GERD (2025) (Gastrointest Endosc) — the first ASGE update since 2014. It endorses PPI as initial therapy with endoscopy reserved for alarm features or refractory symptoms, supports vonoprazan for severe erosive disease, and positions endoscopic and surgical anti-reflux therapy only for objectively confirmed, PPI-refractory GERD proven on pH-impedance testing rather than for symptom-based referral.