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Gastro-Oesophageal Reflux Disease

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Overview

Gastro-oesophageal reflux disease (GORD) describes irritation of the oesophagus secondary to excessive gastric acid reflux. A small amount of acid reflux is normal and protective to the lower oesophagus, however, in GORD it is prolonged and excessive and may lead to inflammation of the oesophagus (oesophagitis).

Epidemiology

  • GORD is relatively common and has an incidence rate of 500 per 100,000 per year
  • GORD is slightly more common in women overall:
    • Men are more likely to have severe oesophagitis
    • Women are more likely to have endoscopy-negative reflux disease 

Risk Factors

  • Smoking and alcohol
  • Obesity
  • Pregnancy
  • Hiatus hernia
  • Family history
  • Stress and anxiety
  • Trigger foods:
    • For example, chocolate and fatty foods delay gastric emptying

Presentation

Overview

The key features of GORD are heartburn and regurgitation, typically after meals. Other associated features may be:

Red flags

Alarm symptoms are features that are associated with underlying malignancy and warrant an urgent referral via a suspected cancer pathway to gastroenterology. These features can be remembered using VBAD:

  • Recurrent vomiting
  • Bleeding, such as melaena (black, tarry stools)
  • Anaemia, abdominal mass, or unintended weight loss
  • Dysphagia

Investigation

Overview

The diagnosis is clinical, however, if any of the following apply, patients should be referred for oesophagogastroduodenoscopy (OGD):

  • Aged >55 years
  • Symptoms lasting >4 weeks
  • Symptoms persisting despite treatment
  • Relapsing symptoms
  • New symptoms that emerge during treatment
  • Any of the aforementioned alarm symptoms

If endoscopy is negative, then 24-hour oesophageal pH monitoring is the gold-standard diagnostic test for GORD.

Management

Uninvestigated dyspepsia

Patients are managed according to the guidelines set out in Dyspepsia.

Endoscopically negative reflux disease

  • 1st-line: full-dose proton pump inhibitor (PPI, such as omeprazole or lansoprazole) for 1 month

Endoscopically proven oesophagitis

  • 1st-line: full-dose PPI for 8 weeks
  • Offer full-dose PPI long-term as maintenance treatment

Complications

Prognosis

Up to 15% of people with GORD symptoms develop Barret’s oesophagus:

  • Of these people, up to 10% develop oesophageal adenocarcinoma over the following 10-20 years

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