Key points
- Acid reflux is very common: in Europe, between 9 % and 26 % of adults have heartburn or regurgitation every week.7
- If symptoms are typical and there are no warning signs, an 8-week trial of treatment can be started without any tests.1
- Omeprazole and similar drugs work far better when taken 30 to 60 minutes before a meal.1
- Losing weight, eating dinner earlier and raising the head of the bed are backed by evidence; long lists of forbidden foods much less so.1,5
- If treatment is needed long term, reflux should be confirmed with a gastroscopy and, if that is normal, with pH monitoring.1,3
- Many people can cut down or stop the medication; others need it indefinitely, and in that case it is safe.4,8
This article summarises the evidence and clinical guidelines so you can understand your situation. It does not replace an individual assessment.
Gastro-oesophageal reflux is the backflow of stomach contents into the oesophagus. Everyone has some reflux after meals; it becomes a disease when it causes troublesome symptoms, such as burning behind the breastbone or regurgitation, or when it damages the oesophagus.1
It has an effective treatment, but it is also one of the conditions most often managed "blind": people who have taken omeprazole for years without anyone confirming the diagnosis, others who take it the wrong way and conclude it does not work, and others whose symptoms are not actually reflux. This article explains how to sort all that out.
What it is and why it happens
Between the oesophagus and the stomach there is a muscular valve, the lower oesophageal sphincter, helped by the diaphragm. When that barrier relaxes too often or weakens, acid and stomach contents travel up into the oesophagus.1
Some factors make it more likely: excess weight, especially around the abdomen; a hiatus hernia, where part of the stomach slides above the diaphragm; smoking; large or late meals; and pregnancy. Weight has a particularly clear effect: in a large study, even women of normal weight who put on weight had more reflux symptoms.6
Typical symptoms and misleading ones
The two typical symptoms are heartburn, a burning feeling that rises from the upper abdomen behind the breastbone, and regurgitation, acid or bitter fluid coming up into the mouth, especially when bending over or lying down.1
| Symptom | What you should know |
|---|---|
| Burning behind the breastbone | Typical symptom. If it responds to treatment, that supports the diagnosis |
| Acid regurgitation | Typical symptom. It responds less well to medication than heartburn |
| Chest pain | It can be reflux, but a heart cause must be ruled out first1 |
| Chronic cough, hoarseness or throat clearing | Reflux is only one possible cause; without typical symptoms it is rarely the culprit1 |
| Pain or heaviness in the upper abdomen | Usually dyspepsia, not reflux; it is investigated differently |
| Difficulty swallowing | Not a usual reflux symptom: it calls for a gastroscopy1 |
Not all heartburn is reflux
Some people with heartburn have an oesophagus that is not exposed to more acid than normal but feels it more intensely. This is called reflux hypersensitivity or functional heartburn, and it is why omeprazole sometimes fails: not because it is the wrong drug, but because the problem is a different one and is treated differently.2,3
When a gastroscopy is needed
If symptoms are typical and there are no warning signs, guidelines allow an 8-week trial of treatment straight away, without tests.1 A gastroscopy is indicated in these situations:
- There are warning signs: difficulty swallowing, weight loss, persistent vomiting, anaemia or signs of bleeding.1
- Symptoms do not improve after 8 weeks of correctly taken treatment.1
- Symptoms come back when treatment stops, or it has to be taken continuously: before committing to indefinite treatment, the diagnosis should be confirmed.1,3
- There are several risk factors for Barrett's oesophagus: many years of reflux, being male, being over 50, abdominal obesity, smoking, or a relative with Barrett's or oesophageal cancer.9
A gastroscopy can show inflammation of the oesophagus, oesophagitis, which is graded from A to D (mildest to most severe), a hiatus hernia or Barrett's oesophagus, a change in the lining of the oesophagus that needs surveillance. Grade B, C or D oesophagitis or Barrett's confirms reflux disease.2
But most people with reflux have a normal gastroscopy. That does not rule out the disease: if symptoms persist and there is doubt, the test that settles it is pH monitoring, which measures over one or more days how much acid reaches the oesophagus and whether it coincides with symptoms. It is done off medication, and it is usually preceded by oesophageal manometry to assess how the oesophagus works.2,3
Which treatment works
Treatment is stepped according to how severe the symptoms are, what the tests show and each person's preferences.1,3
| Treatment | For whom | Worth knowing |
|---|---|---|
| Lifestyle changes | Everyone, as a foundation | Weight loss has the strongest evidence; see below5 |
| Antacids and alginates | Occasional symptoms | Relief within minutes, but they do not heal oesophagitis. Useful on demand |
| Proton pump inhibitors (omeprazole, pantoprazole, esomeprazole…) | Frequent symptoms or oesophagitis | The most effective option. Take them 30-60 minutes before a meal; taken afterwards, they lose much of their effect1 |
| On-demand or intermittent treatment | Controlled symptoms and no significant oesophagitis on gastroscopy | Medication is used only when needed1 |
| Anti-reflux surgery (fundoplication) | Confirmed reflux that is not controlled, or when lifelong medication is not wanted | Very effective in well-selected patients; reflux must first be confirmed with pH monitoring and manometry1,3 |
Why "omeprazole does nothing for me"
Before deciding a treatment has failed, three things need checking: when it is taken (it should be before a meal, not on an empty stomach with no meal afterwards, nor at bedtime), whether it is taken every day during the trial and whether the symptoms really are reflux. Many apparent failures are solved by one of those three adjustments.1,3
The measures backed by evidence
Many measures are recommended, but only some have shown benefit in studies.1,5
| Measure | Evidence | For whom |
|---|---|---|
| Losing weight if overweight | Good: it reduces symptoms and the need for medication5,6 | Anyone who is overweight |
| Raising the head of the bed | Moderate5 | Night-time symptoms |
| Not eating in the 2-3 hours before bed | Moderate1,5 | Night-time symptoms |
| Stopping smoking | Moderate5 | Smokers |
| Avoiding specific foods (coffee, chocolate, spicy food, citrus, alcohol) | Weak as a general rule1 | Only if they clearly trigger your symptoms |
To raise the head of the bed, place blocks under the bed legs or a wedge under the mattress. Extra pillows do not help: they bend the body at the abdomen and can make reflux worse.
When medication can be reduced or stopped
Many people take omeprazole for years without a clear reason. Current recommendations are that all long-term treatment should be reviewed, and reduced or stopped when there is no firm reason to continue.4
| Situation | What is usually done |
|---|---|
| Reflux without significant oesophagitis, symptoms controlled | Try reducing, switching to on-demand use or stopping4 |
| Severe oesophagitis (grade C or D) | Continue: oesophagitis often returns when medication stops1,4 |
| Barrett's oesophagus | Continue indefinitely4,9 |
| History of ulcer or gastrointestinal bleeding | Decide according to risk; it is often continued4 |
| Started "to protect the stomach" with no current reason | Review and, in general, stop4 |
When stopping, it is normal to notice some heartburn for a few days or weeks: the stomach temporarily produces more acid (rebound). It does not mean the disease has come back, and antacids usually control it while it settles.4
What if I need it for good?
When there is a clear indication, long-term treatment is safe. In a trial of more than 17,000 people followed for three years, pantoprazole did not increase dementia, kidney disease, fractures or cancer compared with placebo; only a small increase in gut infections was seen.8 What matters is taking it when it is indicated, at the lowest effective dose.
Common myths
“Omeprazole is a stomach protector.”
It reduces acid production. It only "protects" in specific situations, such as when taking anti-inflammatories with a risk of ulcers. Taking it for no reason brings no benefit.4
“Omeprazole causes dementia and cancer.”
Those associations came from observational studies. A large controlled trial did not confirm them.8
“If I have reflux, the gastroscopy will be abnormal.”
Most people with reflux have a normal gastroscopy. If in doubt, the test that confirms it is pH monitoring.2
“A glass of milk soothes heartburn.”
It soothes for a few minutes but then stimulates acid production. It is not a treatment.
“You should sleep on several pillows.”
Pillows bend the body and can make reflux worse. What works is raising the head of the whole bed.5
“I have a hiatus hernia, so I need an operation.”
Hiatus hernias are very common and almost never need surgery. Surgery treats uncontrolled reflux, not the hernia itself.1
Warning signs: do not wait
See a doctor promptly if…
Reflux is rarely serious, but these symptoms should not be put down to it without a gastroscopy first:
- You find it hard to swallow or food gets stuck
- You are losing weight without trying
- You have persistent vomiting
- You vomit blood or dark material like coffee grounds, or your stools are black
- You have been found to have anaemia
- Symptoms start for the first time after the age of 50-60
If you have severe, tight or exertional chest pain, go to A&E: a heart problem must be ruled out before thinking of reflux.
How I approach it in clinic
I start with the symptoms: what they are, when they appear, what relieves them and whether there are any warning signs. I also go over how and when you take your medication, because some of the cases that arrive as "not responding" are solved simply by changing when the dose is taken.
If symptoms are typical and there are no warning signs, we plan a proper treatment trial together with the lifestyle changes that genuinely apply to you. If it does not work, symptoms come back on stopping, or there are risk factors, I perform a gastroscopy under sedation. And if the gastroscopy is normal and doubts remain, I complete the work-up with oesophageal manometry and pH monitoring, especially before considering surgery or indefinite treatment.
The goal is not only for you to feel well, but to know what you have and to take just the right amount of medication: no longer than necessary and no less than what protects you.
Have you had heartburn for a while, or been taking omeprazole without knowing whether you need it?
We review your case, clarify the diagnosis and adjust the treatment.
Frequently asked questions
Can reflux be cured?
How long do I need to take omeprazole?
Can I take it only when I have symptoms?
Yes. For many people with controlled symptoms and no significant oesophagitis, on-demand treatment is a good option.1
Can reflux cause cancer?
Many years of reflux can lead to Barrett's oesophagus, which increases the risk of oesophageal cancer, although that risk remains low. That is why a gastroscopy is recommended for people with several risk factors.9
What is pH monitoring and when is it done?
Can reflux cause a cough or hoarseness?
It can, but these symptoms have many other causes. Without heartburn or regurgitation, reflux is an unlikely cause and others should be looked for too.1
References
- Katz PO, et al. ACG Clinical Guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022. PubMed
- Gyawali CP, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024. PubMed
- Yadlapati R, et al. AGA Clinical Practice Update on the personalized approach to the evaluation and management of GERD: expert review. Clin Gastroenterol Hepatol. 2022. PubMed
- Targownik LE, et al. AGA Clinical Practice Update on de-prescribing of proton pump inhibitors: expert review. Gastroenterology. 2022. PubMed
- Ness-Jensen E, et al. Lifestyle intervention in gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2016. PubMed
- Jacobson BC, et al. Body-mass index and symptoms of gastroesophageal reflux in women. N Engl J Med. 2006. PubMed
- El-Serag HB, et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014. PubMed
- Moayyedi P, et al. Safety of proton pump inhibitors based on a large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology. 2019. PubMed
- Shaheen NJ, et al. Diagnosis and management of Barrett's esophagus: an updated ACG guideline. Am J Gastroenterol. 2022. PubMed
Links go to PubMed or the original publication and open in a new tab.
Related reading
Dr Fernando Casals Seoane
Consultant gastroenterologist with a PhD in Medicine from the Autonomous University of Madrid. He has worked at La Princesa University Hospital since 2009 and sees private patients at Ruber Juan Bravo Hospital. Certified by the European Board of Gastroenterology and Hepatology and honorary lecturer at the UAM. Principal investigator in international clinical trials on acute pancreatitis, including WATERFALL (NEJM, 2022).
Transparency: this article is not sponsored and does not promote any product or brand. All sources are linked.