Gastro Oesophageal Reflux Disease

Presentation

  • Heartburn
  • Retrosternal discomfort
  • Odynophagia (pain on swallowing)
  • Chronic hoarseness

History

  • Precipitating factors: After meals? Worse when lying down?
  • Lifestyle factors: Smoking and alcohol history, coffee consumption, spicy and fatty foods
  • Ask Pregnancy
  • Drug History: Tricyclic antidepressants, anticholinergics, nitrates and calcium-channel blockers can precipitate
  • Family history of heartburn

Examination

Bedside tests

Laboratory investigations

Do not test for H.Pylori - NICE found no evidence for H. pylori investigation in people with GORD

Radiological investigations

Refer for endoscopy if:
* Patient has atypical, relapsing, or persistent symptoms
* Patient presents with haematemesis
* Patients aged 55 or over with either treatment resistant dyspepsia, upper abdominal pain with low haemoglobin levels or raised platelet count who also have any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
*Patients with nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Management

First line

*Simple advice regarding lifestyle factors that may affect reflux (e.g weight loss if applicable, not eating just before going to bed).
*Offer a full-dose proton pump inhibitor for 1 month:
*Esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole
*Note, there is limited evidence for the effectiveness of antacids and alginates

Second line

  • If symptoms recur after initial treatment, offer a further month of full-dose PPI

*For severe and persisting symptoms, double the dose of the PPI or switch to an alternative PPI for a further month

  • Offer H2RA therapy if there is an inadequate response to a PPI
  • Cimetidine, famotidine, nizatidine, and ranitidine
  • Consider laparoscopic fundoplication for people who have confirmed GORD and are responding to acid suppression therapy, but cannot tolerate it or do not wish to continue this therapy long-term

Follow up

*Routine follow up after initial treatment with PPI is not required
*However, ask the patient to return if symptoms persist
*For patients with frequently recurring symptoms, consider the need for long-term treatment with a PPI to control symptoms - offer a PPI at the lowest dose possible to control symptoms

Complications of GORD

*Side-effects of PPIs include: nausea, vomiting, abdominal pain, flatulence, diarrhoea, constipation, and headache
*Barrett’s oesophagus: Patients with GORD are at increased risk of developing Barrett’s oesophagus. Consider endoscopy if Barrett’s oesophagus is suspected due to long-standing symptoms
*Oeosphagitis
*Peptic ulcers
*Oesophageal stricture

Prognosis

*Up to 80% of people successfully treated for GORD will experience a recurrence of symptoms within 1 year.
*NICE recommends a trial period without medication is appropriate, although most people will need further treatment

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License