Gastro-oesophageal reflux disease (GORD)

Symptoms of GORD:

Heartburn
Regurgitation of gastric contents into the mouth
Waterbrash (excessive salivation)
Chest pain

Diagnosis
The diagnosis of GORD is usually made on the clinical history. Typically, patients will describe retrosternal burning (“heartburn”), often at night or on stooping. Up to half of reflux patients have atypical symptoms including upper abdominal pain, bloating, nausea/vomiting. The onset of symptoms is frequently associated with weight gain.

Who to refer, who not to refer, how to refer

Before considering referral for endoscopy / or oesophageal cell collection device (Cytosponge):

Undertake medication review to look for drugs which make cause or exacerbate symptoms
- NSAIDs
- Corticosteroids
- Opioids including codeine-based analgesia
- Calcium channel antagonists
- Nitrates
- Theophyllines
- Bisphosphonates
Consider alternative diagnoses including:
- Gallstone or biliary disease (especially if severe, episodic pain)
- Cardiac disease
- Normal endoscopy-treat as Functional Dyspepsia (FD)
- Previous oesophagitis-treat as GORD/oesophagitis

GORD is very common, affecting up to 20% of the adult population at any given time

Patients usually complain of a combination of

heartburn (an uncomfortable burning sensation in the chest that often occurs after eating)
acid reflux (where stomach acid comes back up into the mouth and causes an unpleasant, sour taste)
bloating and belching
nausea and/or vomiting

Referral for further tests is seldom necessary in younger patients

See Primary Care Management for those aged <55 years

However, AGE (55 years or over) is an important determinant of pathology

Consider urgent referral if any combination of the following in a patient 55 years old or over
Unexplained weight loss with Upper GI symptoms or anaemia
Iron deficiency anaemia (if >55 yrs and in the presence of GI symptoms
Dysphagia (interference of the swallowing mechanism at any age) OR
Odynophagia (pain on swallowing at any age)
Persistent vomiting

PLEASE SEE DYSPHAGIA PAGE FOR FULL GUIDANCE

New onset abdominal pain or discomfort (>55 yrs)
New or worsening abdominal pain or discomfort combined with one or more of the following features (any age):
- unexplained weight loss
- unexplained iron deficiency anaemia
- persistent vomiting more than 2 weeks
Upper gastrointestinal pain or discomfort combined with one of following risk factors (any age):
- family history of oesophago-gastric cancer in more than two first-degree relatives
- family history of Familial Adenomatous Polyposis (FAP) in any first-degree relative
- Barrett’s oesophagus
- pernicious anaemia
- gastric surgery over 20 years ago
- known dysplasia, atrophic gastritis or intestinal metaplasia

PLEASE SEE URGENT SUSPECTED UPPER GI CANCER FOR FULL GUIDANCE

How to refer:

Refer via SCI Gateway

Borders General Hospital -> Endoscopy -> B Endoscopy

Primary care management

In the absence of alarm symptoms in those aged <55 years:

Consider life changes

Achieve and maintain healthy weight, avoid food triggers, avoid smoking, reduce caffeine intake, modify alcohol intake, avoid eating or drinking for 3hr before bed. Elevating the head of the bed with 4-6inch wooden blocks can help nocturnal reflux

Trial of alginates as required

Treat with full dose PPI (omeprazole 20mg-40mg od or equivalent) for 4 weeks

If symptoms recur offer ongoing PPI therapy but step-down treatment to lowest effective dose
Discuss use of “as required” treatment to encourage self- management of symptoms
Offer an H2RA (Famotidine 20-40mg OD if inadequate response to PPI (this can be added in at bedtime in addition to PPI therapy if required)
Secondary Care would consider using a prokinetic such as Metoclopramide 10mg TID or Domperidone 10mg TID for 4-8 weeks if inadequate response to PPI and no contra-indications, however this is unlicensed use and is not listed on the formulary for this indication.
Offer annual review to assess symptom control and reduce or withdraw treatment if possible

Special considerations

Previous oesophageal stricture dilatation

remain on long term BD PPI

Endoscopically diagnosed severe oesophagitis

offer BD PPI for 8 weeks
if no healing consider

High dose PPI (e.g. omeprazole 40mg once daily or BD)
Switch to another PPI at full dose or high dose (in relative terms, pantoprazole is the ‘weakest’ PPI and Esomeprazole and Rabeprazole are the most potent, compared to Omeprazole) (see Resources and Links section for more info on relative PPI potencies)