**8. Treatment**

Dietary changes and lifestyle modifications are the first steps in the treatment of GERD. This includes eating low-fat and low-acid diet, small meal size, weight loss, smoking cessation, and controlling alcohol consumption. Stress management is also useful. Patients with nocturnal reflux have to eat a meal 2–3 h before bedtime and elevate the head of the bed during sleep. If these measures fail to achieve results, the widely accepted empirical management of LFR and GERD is proton pump inhibitor (PPI) treatment applied twice a day for two or three months. These drugs can suppress acid production and neutralize acidopeptidic activity in esophagus, larynx, and pharynx. PPIs are fast and strong, and the most efficacious and important factor for success of the therapy is their regular and correct usage. Patients who need PPI therapy for a longer time should be placed on the lowest dose because the long-term use of PPIs increases the risk of many complications, such as acute nephritis, gastric tumors, bacterial gastroenteritis, bone fractures, etc. [23, 28].

H2 receptor blockers are an effective alternative maintenance therapy for GERD and LPR, as well as alginates. Alginate forms a gelatinous layer on top of the gastric contents and makes a mechanical barrier, thereby reducing contact between the reflux contents and esophageal mucosa. Alginate also has a significant inhibitory effect on pepsin, and is, according to some research, non-inferior to PPI [13, 29]. Other noninvasive treatment options include using external upper esophageal sphincter compression device. If there is no response to appropriate empirical

treatment, instead of increasing the dose or extending the duration of treatment, it is necessary to review the diagnosis by considering the multifactorial pathophysiology of reflux. In patients with severe reflux, surgical therapy can also be used. Endoscopic and surgical options include anti-reflux surgery, bariatric surgery, magnetic sphincter augmentation, and transoral incisionless fundoplication [22]. As can be seen, the medicament treatment of GERD and LPR is similar, but in clinical practice, patients with LPR require more aggressive and prolonged PPI treatments (six months) to achieve an improvement of laryngeal symptoms than those with typical GERD symptoms [30].
