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Endoscopic management of GERD has a long way to go in carefully selected patients in a 65 year male

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Endoscopic management of GERD has a long way to go in carefully selected patients

14/07/2026

Introduction

Gastroesophageal reflux disease (GERD) has traditionally been regarded as a disorder predominantly affecting Western populations; however, contemporary epidemiological evidence indicates that GERD represents a substantial and growing health burden in India. Rapid urbanization, dietary transitions, rising obesity, and lifestyle factors such as tobacco use have contributed to an increasing prevalence of reflux symptoms across both urban and rural populations.

  1. A recent meta-analysis estimated the pooled prevalence of GERD in the Indian population to be approximately 15 to 16%, with reported prevalence ranging from 7.6 to nearly 30% across different regions and study methodologies.
  2. Community-based studies from southern India have reported symptom-defined GERD prevalence as high as 22.2%, particularly among urban residents and individuals with elevated body mass index.
  3. Importantly, rural Indian studies still demonstrate prevalence rates of around 10 to 11%, indicating that GERD is not confined to urban populations.

Methods

A literature search was conducted in PubMed, Embase, and Google Scholar up to 2025 using terms related to GERD and endoscopic therapies (e.g., antireflux mucosectomy [ARMS], antireflux mucosal ablation [ARMA], Stretta, TIF, GERDx, India). Randomized trials, observational studies, reviews, and guidelines reporting clinical outcomes were included; small case series and non-English studies were generally excluded.

Data were extracted on study design, interventions, outcomes, and safety, and synthesized narratively based on mechanism (neuromodulation, mechanical, mucosal, hybrid) with emphasis on relevance to Indian practice.

Current Standard of Care in India

  1. GERD management in India is largely pharmacotherapy-driven, with proton pump inhibitors (PPIs) as first-line due to efficacy and affordability, often used empirically without diagnostic confirmation.
  2. Adjuncts such as H2 blockers, antacids, alginates, and prokinetics are common, yet 30 to 40% of patients have persistent or relapsing symptoms.
  3. Potassium-competitive acid blockers like Vonoprazan offer faster, more sustained acid suppression and are emerging alternatives.
  4. Surgery, particularly laparoscopic fundoplication, is limited to select refractory cases and has relatively low uptake.
  5. Advanced diagnostics remain restricted to tertiary centers, creating a gap that highlights the potential role of endoscopic therapies.

Pathophysiologic Basis for Endoscopic Antireflux Therapy

GERD results from a combination of functional and structural abnormalities at the gastroesophageal junction (GEJ), including impaired lower esophageal sphincter (LES) competence, increased GEJ distensibility, transient LES relaxations, hiatal hernia, and disruption of the gastroesophageal flap valve.

Medical therapy, particularly PPIs, effectively suppresses gastric acid but does not correct the underlying mechanical defect. Endoscopic antireflux therapies are therefore best suited for carefully selected patients with preserved anatomy and predominantly functional GEJ dysfunction.

  1. Reduce junctional distensibility and improve GEJ competence.
  2. Induce fibrosis to strengthen the antireflux barrier.
  3. Reinforce the gastroesophageal flap valve and restore barrier function.

In contrast, surgical fundoplication remains the preferred approach for patients with large hiatal hernias or significant structural disruption, as it directly repairs the hiatus and restores the antireflux barrier. Thus, improved characterization of GERD phenotypes has positioned endoscopic therapies as a minimally invasive option between long-term medical therapy and surgery.

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