Intended for healthcare professionals

Clinical Review State of the Art Review

Advances in the diagnosis and management of gastroesophageal reflux disease

BMJ 2020; 371 doi: (Published 23 November 2020) Cite this as: BMJ 2020;371:m3786
  1. David A Katzka, professor of medicine1,
  2. Peter J Kahrilas, professor of medicine2
  1. 1Mayo Clinic, Division of Gastroenterology and Hepatology, Rochester, MN, USA
  2. 2Northwestern University, Feinberg School of Medicine, Department of Medicine, Chicago, IL USA
  1. Correspondence to PJ Kahrilas p-kahrilas{at}


Gastroesophageal reflux disease (GERD) is a multifaceted disorder encompassing a family of syndromes attributable to, or exacerbated by, gastroesophageal reflux that impart morbidity, mainly through troublesome symptoms. Major GERD phenotypes are non-erosive reflux disease, GERD hypersensitivity, low or high grade esophagitis, Barrett’s esophagus, reflux chest pain, laryngopharyngeal reflux, and regurgitation dominant reflux. GERD is common throughout the world, and its epidemiology is linked to the Western lifestyle, obesity, and the demise of Helicobacter pylori. Because of its prevalence and chronicity, GERD is a substantial economic burden measured in physician visits, diagnostics, cancer surveillance protocols, and therapeutics. An individual with typical symptoms has a fivefold risk of developing esophageal adenocarcinoma, but mortality from GERD is otherwise rare. The principles of management are to provide symptomatic relief and to minimize potential health risks through some combination of lifestyle modifications, diagnostic testing, pharmaceuticals (mainly to suppress or counteract gastric acid secretion), and surgery. However, it is usually a chronic recurring condition and management needs to be personalized to each case. While escalating proton pump inhibitor therapy may be pertinent to healing high grade esophagitis, its applicability to other GERD phenotypes wherein the modulating effects of anxiety, motility, hypersensitivity, and non-esophageal factors may dominate is highly questionable.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: Both authors contributed equally to the conception, analysis, interpretation of data, drafting, revising, and final proofing of the work. PJK is the guarantor of the work.

  • Funding: PJK was supported by P01 DK092217 (PI: John E Pandolfino) from the US Public Health Service.

  • Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: PJK has advised Ironwood on drug development for GERD, and Bayer on drug development to treat chronic cough, and received grants from the US National Institute of Health and Ironwood Pharmaceuticals outside the scope of this article. DAK is a member of the governing board for the American Gastroenterological Association (no relation to this article), undertook research (unpaid) for Shire and Celgene, and gave a lecture on eosinophilic esophagitis to Celgene.

  • Further details of The BMJ policy on financial interests are here:

  • Provenance and peer review: commissioned; externally peer reviewed.

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