Do You Have GERD—or NERD?

Most people have heard of gastroesophageal reflux disease, commonly known as GERD. But you may be less familiar with NERD—which stands for non-erosive reflux disease—a common but often misunderstood subtype of acid reflux.

In GERD, stomach acid flows backward from the stomach into the esophagus, causing symptoms such as heartburn, regurgitation, and chest discomfort. Over time, this repeated acid exposure can damage the lining of the esophagus, leading to erosions or tears. If left untreated, those changes may result in bleeding ulcers, scar tissue that makes swallowing difficult, or Barrett’s esophagus, a condition marked by abnormal cell changes that increase the risk of esophageal cancer.

NERD is different. While it causes many of the same symptoms as GERD—including heartburn, acid reflux, and chest pain—it does not lead to visible damage to the esophageal lining. That distinction can make NERD harder to diagnose, even though symptoms may feel just as uncomfortable or disruptive.

NERD, or non-erosive reflux disease, is a form of GERD in which people experience chronic acid reflux symptoms but have a normal-appearing esophagus on endoscopy. In other words, stomach acid triggers symptoms without causing erosions, ulcers, or visible inflammation that can be seen during a standard exam.

“If we are strictly talking about symptoms, NERD can be equally as problematic as GERD,” says Catiele Antunes, MD, a Yale Medicine gastroenterologist. “However, since it does not manifest with esophageal damage, including esophagitis, strictures, Barrett's esophagus, the long-term consequences and risk of serious complications are lower.”

NERD is diagnosed when a person has persistent reflux symptoms but visual inspection reveals no esophageal damage. The diagnosis is often confirmed with specialized acid-measuring tests.

When someone sees a primary care provider or gastroenterologist for ongoing heartburn or reflux symptoms, the evaluation typically begins with a review of overall health and a detailed discussion of symptoms, including how often they occur and what seems to trigger them.

If first-line treatments—such as lifestyle changes or over-the-counter medications—don’t provide relief, or if there’s concern about possible esophageal damage, a provider may recommend an upper endoscopy.

During an upper endoscopy, a thin, flexible tube with a small camera and light is passed through the mouth and into the digestive tract. This allows the physician to examine the esophagus, stomach, and the first part of the small intestine for signs of inflammation, ulcers, or erosions, and to take tissue samples if needed.

With NERD, doctors rely on additional testing to confirm that acid reflux is responsible for the symptoms.

One option is a 24-hour pH monitoring test, which measures how often and for how long stomach acid flows back into the esophagus. This test involves placing a thin tube through the nose into the esophagus and leaving it in place for 24 hours to track acid exposure during normal daily activities.

Another approach uses a wireless capsule that, during an upper endoscopy, is temporarily attached to the wall of the esophagus. The capsule records acid levels over several days and transmits the data to a recording device the patient carries around with them. It detaches on its own and passes through the digestive system and is flushed down the toilet.

NERD is treated by reducing acid exposure and managing symptoms, starting with lifestyle changes and progressing to medication or procedures when needed.

“Weight loss directly correlates with improvement of symptoms and decrease in acid exposure,” Dr. Antunes says.

For most people with NERD—or any form of acid reflux—treatment begins with identifying triggers that worsen symptoms. “We want to identify if there are things we are doing in our day-to-day life that make us more prone to acid reflux,” Dr. Antunes says. “Sometimes, these are very simple changes, like not having a heavy dinner or not eating too close to bedtime. Or if you know alcohol or certain foods trigger heartburn, avoid those.”

If lifestyle adjustments aren’t enough, the next step is usually medication to reduce stomach acid. This often includes proton pump inhibitors (PPIs) such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium).

If these medications don’t help, one newer option is vonoprazan, a potassium-competitive acid blocker that suppresses acid in a different way than traditional PPIs.

For people with NERD who have severe reflux symptoms that aren’t well controlled with medication, surgical or endoscopic procedures may be considered, but they are not for everyone, Dr. Antunes says. “There is a newer procedure called transoral incisionless fundoplication, or TIF, for a select group of patients with significant reflux symptoms who do not want to stay on medical therapy or are not candidates for other surgical options,” she explains. “There are also many studies underway looking at different endoscopic techniques to treat reflux.”

Dietary advice for NERD should be individualized rather than one-size-fits-all, Dr. Antunes emphasizes. “There really isn’t good data saying that you have to avoid things like chocolate, black tea, carbonated, or caffeinated beverages,” she says. “These can be triggers, but not for everyone. It’s more likely to be a problem if you’re eating large, fatty meals right before bed. If you enjoy tea and it’s not a problem for you, life is too short not to enjoy it.”

NERD can affect people of any age, but acid reflux in general becomes more common with age. Increasingly, though, the problem is being seen in younger adults.

“The reasons aren’t completely clear, but we know obesity rates have increased, and reflux is strongly associated with obesity,” Dr. Antunes says.

Smoking is another major risk factor for acid reflux and its complications, and there are some studies suggesting vaping—marijuana and nicotine—also increase the risk of GERD, she adds.

“There’s a higher rate of Barrett’s esophagus in older white men, especially those who smoke and are obese,” she says. “Barrett’s is a precancerous condition, and sometimes we find esophageal cancer in people who never had typical reflux symptoms.”

For that reason, screening is recommended for certain higher-risk groups. “We suggest patients who have at least three established risk factors from the following: age greater than 50, male sex, Non-Hispanic White, obesity, history of smoking, chronic reflux symptoms, or a family history of Barrett’s or esophageal cancer be screened for Barrett’s esophagus, which may include an upper endoscopy,” Dr. Antunes says.

But some studies suggest that NERD itself may be more common in women than in men.

Dr. Antunes encourages anyone with ongoing heartburn or reflux symptoms—especially symptoms that don’t improve with simple treatments—to talk with their primary care provider. If needed, they can be referred to a gastroenterologist for further evaluation and a personalized treatment plan.