Most people meet acid reflux at some point in their lives. A heavy curry, too much wine, lying down straight after a big meal – your chest burns, there’s a sour taste in the back of your throat, and you promise you’ll “never do that again”.
For a lot of my patients, though, it doesn’t stop there. The burning becomes almost daily. Tablets start to live in handbags and bedside drawers. Sleep is disrupted, certain foods are avoided, and there’s a quiet, nagging question underneath it all:
“Is this just reflux… or is something more serious going on?”
If that sounds familiar, this article is for you.
I’ll walk you through how I think about reflux in clinic: when we can manage it simply, when we should look inside with an endoscopy, what Barrett’s oesophagus actually means, when tests like manometry and pH studies are worth doing, how surgery fits in, and how worried you really need to be about long-term PPI use.
When heartburn is more than just an annoyance
Reflux itself is incredibly common and, in many people, fairly harmless. A bit of acid coming up now and then after certain meals is part of being human.
What worries me is a different pattern: heartburn or regurgitation most days of the week, symptoms going on for months or years, or chest and throat symptoms that simply won’t settle despite doing “all the right things”.
When I meet someone with long-standing reflux, the first job is to listen properly. How long has this been going on? Does food ever feel like it sticks? Is there pain when swallowing? Have you lost weight without trying? Is there a family history of oesophageal or stomach cancer? Have you been on acid-suppressing tablets for years without anyone really checking what’s happening in the oesophagus?
That combination of story, age, and risk factors is what tells me whether we can safely keep treating on the surface – or whether it’s time to actually look.
Why and when I recommend an endoscopy
Endoscopy (a camera test of the gullet and stomach) is not something I throw at every patient with heartburn. For many younger people with mild symptoms that respond well to a short course of acid suppression, it’s simply not necessary.
But there are situations where I feel strongly that we should do it.
If you are over about 50 with persistent reflux, especially if you’re male and carry weight around the middle, I start thinking about getting a proper look. If food sticks or hurts on the way down, if you’ve unintentionally lost weight, if your GP has found low iron or anaemia, if you’ve had black stools or vomited blood, an endoscopy moves from “optional extra” to “essential”.
Even without dramatic alarm bells, years of daily or near-daily reflux in someone with several risk factors often tips the balance towards at least one scope. It’s not about scaring people; it’s about not crossing our fingers and hoping for the best when we don’t have to.
What does the test actually give us? It shows whether the oesophagus is inflamed or ulcerated, if there is a hiatus hernia, whether there are any concerning strictures or lumps, and crucially, whether the lining at the bottom of the oesophagus has changed into Barrett’s oesophagus.
Barrett’s oesophagus in plain language
Barrett’s is one of those phrases that sends people straight to Google at midnight.
In simple terms, the lower part of your oesophagus isn’t designed to be bathed in acid and bile all day. If that happens for many years, the lining can adapt and change into a tougher, “intestine-like” lining. That change is called Barrett’s oesophagus.
Why do we care? Because that Barrett’s lining has a higher chance of turning into cancer over time than normal lining. The key point, though, is that the vast majority of people with Barrett’s never develop cancer. It is a risk marker, not a sentence.
If I find Barrett’s during an endoscopy, I always take small biopsies. Under the microscope, we look for signs of “dysplasia” – early but important changes in the cells. No dysplasia usually means periodic surveillance. Low- or high-grade dysplasia may need closer follow-up and, in many cases now, active endoscopic treatment.
The reassuring part is that we’re much better at managing Barrett’s than we used to be. In many patients we can treat abnormal areas from inside the oesophagus using techniques like radiofrequency ablation, rather than big, life-changing surgery. The worst thing is to have Barrett’s and nobody knows about it.
Where PPIs fit in – and how scared you should be of them
By the time people get to me, many have tried most of the pharmacy shelf. Gaviscon, alginates, “over-the-counter omeprazole”, then a prescription PPI from the GP, and sometimes two or three different ones.
PPIs – omeprazole, lansoprazole, esomeprazole, pantoprazole and so on – are among the most effective drugs we have for reflux. They genuinely reduce acid production in the stomach, help the oesophagus to heal if it’s inflamed, and in conditions like Barrett’s they play a protective role.
Understandably, patients are increasingly worried about taking them long term. The internet is full of headlines linking PPIs to bone thinning, kidney disease, dementia and more. What’s rarely explained is that most of these concerns come from observational studies that show an association, not proof that PPIs are the cause. People on PPIs tend to be older, more unwell, and on more medications overall, which itself increases risk.
My approach is fairly straightforward. If you have good evidence of significant reflux disease – troublesome symptoms confirmed on tests, oesophagitis, Barrett’s – then being on a daily PPI is often the right thing to do. The benefit of protecting the lining and controlling acid far outweighs the theoretical risk for most people.
If you’ve been put on a PPI for vague “indigestion” and nobody is really sure what’s going on, then yes, we should be asking whether you still need it, whether the dose is right, and whether another diagnosis has been missed.
I don’t like people taking high doses forever by default, but I also don’t want you to be frightened into stopping a drug that is genuinely helping a real problem. The sweet spot is the lowest dose that keeps symptoms controlled and the oesophagus healthy, reviewed from time to time rather than left on autopilot.
Tests beyond the scope: manometry and pH studies
Endoscopy tells us what the oesophagus looks like. Sometimes that’s enough. Sometimes it isn’t.
If you have difficulty swallowing, chest discomfort that doesn’t quite behave like reflux, or you’re considering anti-reflux surgery, I’ll often suggest a test called oesophageal manometry. It’s not glamorous – a thin tube through the nose for a short while – but it tells us how strongly and how well your oesophagus squeezes, and how the valve at the bottom behaves.
This matters. If the oesophagus is weak or uncoordinated and we do a full, tight anti-reflux wrap around the stomach, we can make swallowing worse. Manometry helps us avoid that.
Then there are pH and pH-impedance studies. These are 24-hour tests that measure how much acid is actually coming up into the oesophagus and when. In some cases we use a thin catheter through the nose; in others, a small wireless capsule clipped to the oesophagus during an endoscopy.
These tests are most useful when the picture is blurred. You might still be getting symptoms despite PPIs and we’re trying to work out whether it’s ongoing reflux, a very sensitive oesophagus, or something else entirely. Or you might have mainly cough, throat clearing or chest symptoms and we want objective evidence before talking about long-term treatment or surgery.
Put simply, manometry and pH studies move us from guesswork to measurement. They’re not for everyone with heartburn, but when chosen carefully they can completely change the management plan.
Is surgery ever the right answer?
For a small number of people, the answer is yes.
Anti-reflux surgery – most commonly some form of laparoscopic fundoplication – aims to strengthen the valve at the bottom of the oesophagus and reduce the amount of acid that can flow back up. In selected patients it can be genuinely life-changing: less heartburn, less regurgitation, less dependence on tablets.
But it is not a magic wand, and it comes with its own trade-offs. Some people notice more bloating, find it harder to belch or vomit, or need time to adjust to a tighter valve when swallowing. That’s why I am very cautious about recommending surgery without proper testing first.
In my mind, surgery is worth discussing if we have shown that you genuinely have significant reflux on objective testing, you have tried sensible medical and lifestyle treatment without enough improvement, and you understand both the potential benefits and the possible downsides. It is a big decision, and it should never be rushed.
So what should you do if you’re living with reflux?
If you’re young, have mild, occasional heartburn that responds easily to small lifestyle changes or a short course of tablets, you probably don’t need to dive into scopes and wires.
If, however, you have had symptoms for years, you’re needing medication most days, you’re over 50, you have any difficulty swallowing, unexplained weight loss, anaemia, or a strong family history of upper gut cancer, then I would rather you had a calm, planned assessment than lived with worry and guesswork.
That assessment might confirm simple reflux and nothing more, in which case we can focus on getting you comfortable with the least medication necessary. It might show Barrett’s, where we can put proper surveillance and protection in place. It might suggest that surgery could genuinely help, or that your symptoms are coming from something completely different.
What I want for my patients is not endless tests for the sake of it, nor blind reassurance without evidence, but a sensible route through the middle: listening properly, investigating when it’s justified, and then making decisions together based on what we actually find.
Reflux is common. Anxiety about reflux is almost as common. If your symptoms are beginning to shape how you eat, sleep and live, or if you’re quietly worried about what might be going on underneath, that’s usually the moment to stop guessing and get a clear plan.
Who is Dr. Arjun Prakash?
Dr Arjun Prakash is a Consultant Gastroenterologist and Endoscopist based in Milton Keynes, offering specialist care for reflux, heartburn and all aspects of digestive health. He sees patients privately at the Saxon Clinic and at a central Milton Keynes clinic, as well as through the NHS at Milton Keynes University Hospital. If you’d like to discuss your symptoms or arrange an appointment, please get in touch using the enquiry form or contact details on this page.
