When acid treatment has not helped
Acid reflux is common: gastro-oesophageal reflux disease affects about 10–20% of people in Western countries. When symptoms are persistent, troublesome or accompanied by warning features, the initial approach is to exclude a worrying cause or complication, such as oesophagitis, an ulcer, a narrowing or Barrett’s oesophagus. Gastroscopy can assess the lining, take biopsies when needed and show anatomical factors such as a hiatus hernia that may exacerbate reflux.
Most people improve with the appropriate dose and timing of medicines. I ask which symptom remains and check how your medicine is taken, because burning behind the breastbone, food or fluid coming back up, difficulty swallowing and upper abdominal discomfort can need different assessments. A small number of people may need surgery when symptoms or complications persist despite appropriate treatment. If we are not sure that reflux is causing your symptoms, reflux monitoring or another test may help more than trying another tablet. New difficulty swallowing or concerning chest pain needs separate assessment. Do not assume it is your usual reflux.
How does reflux happen?
The junction
Muscle at the lower end of the food pipe, the diaphragm and the shape of the junction work together to limit reflux.
The moving red line shows the direction of reflux. The text above explains the same process.
The junction
Muscle at the lower end of the food pipe, the diaphragm and the shape of the junction work together to limit reflux.
Reflux
Stomach contents move up into the food pipe. Reflux can happen even when endoscopy does not show visible inflammation.
Oesophagitis
Reflux can inflame the lining of the food pipe. An examination and, sometimes, biopsies help clarify the finding.
Hiatus hernia with reflux
A sliding hiatus hernia moves the junction above the diaphragm. This can weaken the normal barrier and allow stomach contents to move upwards into the food pipe. The animation shows one possible pattern; a hernia does not always cause symptoms or reflux.
Simplified illustrations, not to scale. These show an example, not your own anatomy or test result.
Read every diagram explanation
The junction
Muscle at the lower end of the food pipe, the diaphragm and the shape of the junction work together to limit reflux.
Reflux
Stomach contents move up into the food pipe. Reflux can happen even when endoscopy does not show visible inflammation.
Oesophagitis
Reflux can inflame the lining of the food pipe. An examination and, sometimes, biopsies help clarify the finding.
Hiatus hernia with reflux
A sliding hiatus hernia moves the junction above the diaphragm. This can weaken the normal barrier and allow stomach contents to move upwards into the food pipe. The animation shows one possible pattern; a hernia does not always cause symptoms or reflux.
Why does reflux happen?
Food passes down the oesophagus into the stomach. Muscle at the lower end of the oesophagus, together with the surrounding diaphragm, helps prevent stomach contents coming back up. This barrier relaxes when you swallow. Reflux happens when contents flow upwards at other times.
Occasional reflux is common. Frequent troublesome symptoms or complications are called gastro-oesophageal reflux disease (GORD). A hiatus hernia can make reflux more likely, but reflux also occurs without a hernia. Symptoms may be worse after meals or when lying down.
What does oesophagitis on my report mean?
Reflux can irritate the oesophageal lining and cause small breaks in its surface. At gastroscopy, reflux oesophagitis may be described using Los Angeles grades A to D. These describe the extent of the surface damage. They are not cancer stages.
Not all oesophagitis is caused by reflux. Medicines, infection and eosinophilic oesophagitis are other possible causes. Biopsies may help clarify the diagnosis.
Some people have troublesome reflux with a normal-looking oesophagus. A normal gastroscopy does not rule out reflux. If symptoms persist, I may consider reflux monitoring or other tests rather than assuming that more acid suppression is always the answer.
How is it treated?
Proton pump inhibitors (PPIs), such as omeprazole, reduce stomach acid. They can relieve reflux symptoms and heal reflux oesophagitis. They do not repair a hiatus hernia or prevent every episode of regurgitation.
Your diagnosis and response guide the medicine plan. Some people can reduce treatment once symptoms settle. Severe oesophagitis often needs ongoing treatment to prevent recurrence. PPIs are generally well tolerated. I review the benefits, side effects and lowest effective dose with you.
If symptoms continue, I check how the medicine is being taken, whether reflux is the correct diagnosis and whether further investigation would help. Surgery or an endoscopic treatment is suitable for selected people after assessment. It is not the next step for everyone.
What can I try at home?
A strict blanket diet is usually unnecessary. Keep eating a varied diet, and reduce foods or drinks that repeatedly trigger your symptoms.
- Try smaller meals and avoid lying down soon after eating, especially before bed.
- For night-time reflux, raising the head of the bed or using a wedge may help.
- If appropriate, gradual weight reduction can improve symptoms. Stopping smoking also helps.
Is this the same as Barrett’s oesophagus?
No. Barrett’s oesophagus is a different change in the lining, assessed at gastroscopy and confirmed through tissue examination. It is not diagnosed simply because you have heartburn or oesophagitis.
Barrett’s oesophagus is a complication associated with reflux that we find in some people, usually after longer-term or repeated reflux. It can increase the risk of oesophageal cancer, but most people with it do not develop cancer.
Follow-up depends on the length of the affected area and whether biopsies show dysplasia (precancerous cell changes). It needs its own treatment and follow-up discussion.
I will document your recommended follow-up in your endoscopy report and/or histology report once any tissue results are available. Severe oesophagitis may need another gastroscopy after treatment to check healing and assess the lining more clearly.
Symptoms to have checked
Contact me or your GP for new difficulty or pain with swallowing, unexplained weight loss, repeated vomiting or symptoms that persist despite treatment.
Seek urgent assessment if food is stuck and you cannot swallow saliva, you vomit blood, have black tarry stools or develop severe chest or upper abdominal pain. New chest pain should not be assumed to be reflux.
Call 111 for new severe chest pain, especially with breathlessness, sweating or faintness, or if you collapse or are too unwell to travel safely.
Three things to remember
- Reflux describes stomach contents flowing upwards. Oesophagitis describes inflammation of the food pipe lining.
- A normal gastroscopy does not rule out reflux. Persistent symptoms may need a different assessment.
- Treatment and follow-up depend on your symptoms and findings. Oesophagitis is not a diagnosis of cancer.
Related information
Sources and further reading
English clinical master checked 15 October 2026.
- Health NZ: heartburn and acid reflux
- ACG: diagnosis and management of reflux disease (2022)
- ASGE: reflux diagnosis and management guideline (2025)
- NIDDK: treatment for reflux disease
- NIDDK: definition and facts for reflux disease
- ACG: Barrett’s oesophagus
- AGA: a personalised approach to reflux assessment, 2022