Rena Yadlapati, MD, on Differentiating Acid vs Nonacid Reflux

Dr Yadlapati review her presentation from the ACG Scientific Meeting on diagnosis of acid reflux vs nonacid reflux and how to approach the treatment and monitoring of these conditions.

Rena Yadlapati, MD, is the director of the GI Motility Lab and program director of the advanced fellowship in esophageal diseases at the University of California San Diego.

GERD Management: Confirm Diagnosis and Address the Reflux Spectrum

• GERD diagnosis: Approximately 80% of patients lack erosive esophagitis. When endoscopy shows no erosive disease, use ambulatory reflux monitoring; wireless pH monitoring can accompany index endoscopy after stopping acid suppression for at least 7 days.
• Acid suppression: Proton pump inhibitors and potassium-competitive acid blockers address acidic reflux. Confirm reflux before considering surgical or endoscopic antireflux interventions.
• Personalized care: Address additional reflux contributors through weight loss, avoiding tight abdominal clothing, head-of-bed elevation, left-side sleeping, and diaphragmatic breathing. Consider alginates and, for overlapping brain-gut interaction disorders, neuromodulators or behavioral therapy.

Speaker 1:

Hi, I'm Rena Yadlapati. I'm a professor at UC San Diego and I focus on esophageal diseases. I’m delighted to be here at ACG in Nashville for the 2026 conference. So we had the opportunity to share at the postgraduate session on the burning question of acid versus nonacid reflux. And I have to say, first of all, this question always bothers me a little bit because even though it's so commonly asked, the truth is that it's not one versus the other. Gastroesophageal reflux has components that are acidic, weakly acidic, nonacidic, and it all lives on a spectrum.

So really when you see a patient that you think has GERD, the first question is, do they actually have GERD? So we need to do the right diagnostic testing. And that may be with a trial of acid suppression if they came in with symptoms like heartburn or regurgitation. Otherwise, you start with objective testing and that's going to be your upper endoscopy looking for erosive esophagitis, assessing the antireflux barrier.

But if there's no erosive disease, which 80% of patients won't have erosive esophagitis, we move forward with ambulatory reflux monitoring. Now that can be done actually at the same time as that upper endoscopy. If you'd ask your patient to stop their acid suppression for at least 7 days, wireless pH monitoring can be placed at that index endoscopy, which is really cost effective and streamlines the process for our patients. So we have wireless pH monitoring or pH impedance, and essentially that'll clench the diagnosis of whether your patient has nonerosive reflux disease or no GERD at all.

And then that's where we start talking about the acid and the nonacid parts. The majority of reflux is acidic. So start with your proton pump inhibitors. Remember that not every PPI is constructed the same, so use ones that may have better profiles in terms of gastric acid suppression. And remember that now we have PCAPs or potassium competitive acid blockers. They're FDA-approved for erosive esophagitis and nonerosive reflux disease.

But there are other components outside of acid that can perpetuate reflux—gastroesophageal pressure or abdominal pressure—counsel your patients on weight loss, but even simple things like avoiding tight clothing around the abdomen, bracing your abdomen properly when you're weightlifting, simple things like that can make a big difference. Remember elevating the head of the bed and sleeping on the left side decreases reflux at nighttime. Diaphragmatic breathing is great for relaxation and also the pressure at the lower esophageal sphincter.

And then some medications that can reduce reflux, whether it's acidic or nonacidic, are alginates or GABA agonists. Now I only use GABA agonists for patients that have transient LES relaxation mediated reflux events, so regurgitation or gastric belching. Gabapentin or GABA agonist can be difficult to tolerate, so something to keep in mind.

And then of course, antireflux interventions, whether they're surgical or endoscopic, are a great option for your patients with reflux. The key is to make sure that they actually have reflux to begin with because if you make a physiologic gastroesophageal flap valve supraphysiologic, that can lead to poor outcomes.

Finally, don't forget about the role of disorders of brain-gut interaction. Whether it's a patient that has more of a functional heartburn presentation or GERD, it can overlap with brain-gut interaction and treating them with neuromodulators or behavioral therapy can be really helpful. So it's not so much about acid versus nonacid, but it's about thinking about the whole spectrum and addressing your patient in a personalized phenotype directed way. Thank you.