Acid reflux and GERD: what causes the burning and when does it need more than antacids

What is GERD and how is it different from ordinary heartburn?

Gastroesophageal reflux disease, GERD, is defined by the repeated backflow of stomach acid into the oesophagus in a way that causes troublesome symptoms or complications. The stomach lining is protected from its own acid by a thick mucus layer, but the oesophagus has no such protection. When the lower oesophageal sphincter, the muscle valve between the stomach and oesophagus, weakens or relaxes at the wrong moment, acid can splash upward and damage the oesophageal lining.

Occasional heartburn after a large meal or a night of rich food is experienced by most people at some point and does not constitute a disease. The threshold for GERD is symptoms occurring two or more times a week, or symptoms causing complications such as oesophageal inflammation, difficulty swallowing, or chronic cough. At that frequency and severity, the condition warrants a medical assessment rather than self-managed antacids.

A 2024 study published in the Journal of Family Medicine and Primary Care found high rates of GERD among adults attending primary care in Bahrain, with obesity, smoking, late eating habits, and certain medications among the most significant associated factors. A 2022 survey of gastroenterologists across Africa and the Middle East published in Expert Review of Gastroenterology confirmed that GERD is a highly prevalent and often undertreated condition across the region.

Why is reflux so common in the Middle East and Gulf?

Late large meals, a social and religious norm across much of the region, are one of the most important contributors to GERD. A full stomach pressed against the lower oesophageal sphincter while lying down exerts far more pressure than in an upright position. Simply waiting two to three hours after eating before lying down, or raising the head of the bed by 15 centimetres, can produce a dramatic improvement in symptoms for many people.

Obesity, whose rates in Gulf countries and Egypt are among the highest in the world, significantly increases reflux risk. Abdominal fat compresses the stomach and raises intragastric pressure. Research consistently shows that losing 10 percent of body weight produces clinically meaningful improvement in reflux symptoms. This is one of the most evidence-based lifestyle recommendations in gastroenterology.

Tobacco and shisha use relax the lower oesophageal sphincter and reduce saliva production. Saliva is bicarbonate-rich and helps neutralise acid that reaches the oesophagus, so reducing it means less natural protection. Coffee, citrus and spicy food are frequently cited by patients as triggers, but the evidence for universal avoidance is weaker than commonly believed. Individual variation is substantial, and an elimination approach guided by a personal food diary is more useful than blanket restriction.

Antacids and proton pump inhibitors: what each drug does

Antacids, such as preparations containing aluminium hydroxide or magnesium carbonate, neutralise the acid already in the stomach and provide relief within minutes. Their effect lasts two to three hours and they do not affect acid production. They are appropriate for occasional symptoms and are safe for use in pregnancy under guidance.

Proton pump inhibitors (PPIs), including omeprazole, pantoprazole and esomeprazole, are the most potent acid-suppressing medications and the first-line drug treatment for confirmed GERD. They work by blocking the enzyme responsible for acid production rather than neutralising acid after the fact. They should be taken 30 minutes before the first meal of the day for maximum effect. Standard treatment courses are four to eight weeks.

The problem is that PPIs are frequently continued for months and years beyond the initial indication without reassessment. A 2026 study in PLoS Medicine highlighted the importance of periodically reassessing PPI use. Long-term use reduces magnesium and vitamin B12 absorption, may increase the risk of certain enteric infections, and has been associated with other effects whose clinical significance is still being studied. The answer is not abrupt discontinuation, which can cause rebound acid hypersecretion, but periodic review with your doctor to confirm continued need.

Lifestyle changes that actually work

The changes supported by the strongest evidence are: waiting two to three hours after eating before lying down, achieving even modest weight loss if overweight, and elevating the head of the bed by 15 to 20 centimetres by placing something under the bed frame, not just adding extra pillows. These three together account for a substantial proportion of GERD symptoms in people who implement them consistently.

Sleeping on the left side is better for reflux than the right side because of the anatomy of the stomach outlet. Right-side sleeping slows gastric emptying and increases the contact time between refluxed acid and the oesophageal lining. Eating smaller, more frequent meals rather than two or three large ones reduces intragastric pressure throughout the day.

Individual trigger foods vary considerably. Rather than avoiding everything conventionally listed, keep a food and symptom diary for two weeks and identify your actual triggers. Many people with GERD tolerate tomatoes, citrus, coffee and spice perfectly well, while others find specific triggers that are not on the standard list. The diary approach is more precise and less likely to unnecessarily impoverish your diet.

When is an endoscopy necessary?

Endoscopy involves passing a thin flexible camera through the mouth to examine the lining of the oesophagus, stomach and upper small intestine. It is not a test that everyone with heartburn needs. However, it is essential, not optional, when certain alarm features are present, because these can indicate serious pathology including oesophageal cancer.

The alarm features that require endoscopy are: difficulty swallowing or pain on swallowing, unexplained weight loss, anaemia without another explanation, vomiting blood or material resembling coffee grounds, and black tarry stools. Additionally, anyone over the age of 50 with new onset of symptoms warrants endoscopic evaluation rather than empirical treatment.

One important finding at endoscopy is Barrett's oesophagus, a change in the type of cells lining the lower oesophagus caused by chronic acid exposure. Barrett's oesophagus does not cause additional symptoms, but it carries a modestly increased risk of oesophageal adenocarcinoma, which is why those diagnosed with it undergo regular surveillance endoscopy. A 2024 review in Annals of Internal Medicine outlines current evidence on GERD management including the role of surveillance in Barrett's disease.

Reflux without heartburn: the atypical presentations

A significant proportion of GERD cases present without the classic burning sensation behind the breastbone. Extraoesophageal reflux can manifest as a chronic unexplained cough, particularly worse when lying down at night, persistent hoarseness especially in the mornings, recurrent throat clearing, or the sensation of a lump in the throat that does not resolve.

These presentations frequently lead patients to ENT specialists or respiratory physicians before reflux is identified as the cause. If you have been treated repeatedly for throat infection or chronic cough without improvement, it is worth mentioning any degree of heartburn or sour taste to your doctor so that reflux can be considered in the investigation.

In infants, silent reflux presents as crying after feeds, partial vomiting, feeding refusal, and poor weight gain. Most infants improve as the lower oesophageal sphincter matures. Severe cases may require investigation and treatment, but routine pharmacological treatment is not recommended for all infants with reflux.

Reflux during Ramadan: a specific regional challenge

Ramadan creates a specific pattern that is favourable for GERD symptoms. Iftar is often a large meal on a completely empty stomach after a long fast, followed by socialising, tea and dessert. Suhoor is eaten in the middle of the night and sleep follows immediately afterward. Both eating patterns directly reproduce the conditions that worsen reflux.

Despite this, some patients notice improved symptoms during Ramadan if they avoid excessively fatty foods and do not oversleep after Suhoor. The key adjustments are the same as for any GERD management: eat moderately at Iftar, wait before lying down, and avoid carbonated drinks which are heavily consumed at Iftar tables and increase gastric distension.

If you take a PPI, the timing can be adjusted for Ramadan. Take it 30 minutes before Iftar, or before Suhoor, depending on which meal is larger and when symptoms are worst. Your doctor can advise on the specific drug and dose you are using.

Foods that help or worsen reflux in a regional diet

The conventional list of foods to avoid for reflux (tomatoes, citrus, coffee, chocolate, mint, fatty food) is often presented as universal, but research shows individual variation is large. Rather than adopting the entire list, a two-week food diary identifying your personal triggers is more useful and less likely to unnecessarily restrict your eating. A 2024 clinical review in Annals of Internal Medicine notes that evidence for dietary restriction beyond overall meal size and timing is limited.

Foods that many regional GERD patients find soothing include warm aniseed or fennel tea after meals, plain yoghurt, and oatmeal, which coats the oesophagus and has a mild buffering effect. Bananas and bread are generally well tolerated. By contrast, tea drunk in large quantities on an empty stomach, strong coffee before breakfast, and very spicy dishes eaten late at night are frequent triggers worth testing individually.

Carbonated drinks deserve particular mention because they are consumed heavily at iftar and at social gatherings. The carbon dioxide dissolved in these drinks expands in the stomach, increasing intragastric pressure and driving acid upward. Replacing them with still water, diluted juice, or herbal tea is one of the more impactful single changes a person with reflux can make at mealtimes.

Distinguishing heartburn from cardiac chest pain

Oesophageal pain and cardiac chest pain can be remarkably similar and the distinction genuinely matters. Heartburn typically occurs 30 to 60 minutes after eating, is burning in character, is relieved by antacids, and is positional, worse when lying flat. It does not usually radiate to the jaw or left arm and is not accompanied by breathlessness or sweating.

Cardiac chest pain more often occurs with exertion or strong emotion, is described as pressure, tightness or heaviness rather than burning, may radiate to the left arm, jaw or back, and is accompanied by breathlessness, sweating, or palpitations in more severe cases. It is not reliably related to meals and is not relieved by antacids.

When there is any doubt, the correct action is medical assessment, not self-diagnosis. Both cardiac disease and GERD are common in the regional adult population, and presenting with chest pain warrants evaluation for both. Oesophageal spasm, a less common but real condition, produces chest pain indistinguishable from cardiac pain and requires specialised testing to identify.

Sources

• Alqassab DF, Hasan MJ, AlSaadoon AM et al: Prevalence and risk factors of gastroesophageal reflux disease among adults attending primary healthcare in Bahrain, Journal of family medicine and primary care, 2024
• Al-Marhabi A, Hashem A, Zuberi BF et al: The views of African and Middle Eastern Gastroenterologists on the management of mild-to-moderate, non-erosive gastro-esophageal reflux disease (GERD), Expert review of gastroenterology and hepatology, 2022
• Delavari A, Moradi G, Birjandi F et al: The Prevalence of Gastroesophageal Reflux Disease (GERD) in the Islamic Republic of Iran: A Systematic Review, Middle East journal of digestive diseases, 2012
• Dunbar KB: Gastroesophageal Reflux Disease, Annals of internal medicine, 2024
• Sawaid IO, Din Z, Golan E et al: Association between proton pump inhibitor use and upper gastrointestinal cancer: A matched case-control study, PLoS medicine, 2026
• American College of Gastroenterology: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease, 2022