What Actually Causes GERD and Acid Reflux? Why Long-Term PPI Use Often Makes It Worse — Frequently asked questions about GERD and PPI use

Is GERD really caused by too much stomach acid? In most cases, no. GERD is caused by lower esophageal sphincter dysfunction allowing stomach contents to flow back into the esophagus. The acid is what produces the burning sensation when reflux occurs, but the amount of acid is rarely the primary issue. Many GERD patients have normal or even reduced gastric acid output on careful testing. The LES is the actual lesion. Why does my PPI not work as well as it used to? The most common reasons are: tolerance development at the parietal cell level (less common than people think); progression of the underlying LES dysfunction (continuing while the symptom is suppressed); development of SIBO secondary to the PPI use (creating pressure from below that the PPI cannot address); and weight gain or other lifestyle factors that increase the mechanical pressure. The medication is doing what it was designed to do; the underlying disease is progressing through mechanisms the medication does not address. Are PPIs safe long-term? The risk-benefit assessment has evolved. PPIs are appropriate for short-term use (weeks to months) for active reflux disease. Long-term use (years) is associated with increased risk of SIBO, B12 deficiency, magnesium depletion, fractures, C. difficile infection, pneumonia, and possibly cognitive decline. None of these risks are dramatic individually, but they accumulate ov