Gastro-oesophageal reflux disease

Overview

•Heartburn - retrosternal burning, worse after meals, lying down, bending; relieved by antacids

•Acid regurgitation - effortless return of acidic fluid, sour/bitter taste

•Atypical/extraoesophageal symptoms (laryngopharyngeal reflux / 'silent reflux') - chronic cough, hoarseness, globus sensation, worsening asthma, dental erosions; may occur without heartburn; erythema on laryngoscopy

🚨
Dysphagia is a RED FLAG - do NOT attribute it to uncomplicated GORD. New dysphagia at any age requires urgent OGD (2-week-wait referral). Progressive dysphagia (solids first, then liquids) + weight loss = exclude oesophageal cancer.

•Other red flags warranting urgent OGD: unintentional weight loss (≥55 yrs with dyspepsia), haematemesis/melaena, persistent vomiting (≥55 yrs), iron-deficiency anaemia with upper GI symptoms

Investigations

•Clinical diagnosis - typical heartburn/regurgitation in <55 yrs with no red flags; no investigation needed before PPI trial

•First-line investigation: OGD (oesophagogastroduodenoscopy) - indicated for red flag symptoms, treatment-resistant GORD, age ≥55 with weight loss/dyspepsia (urgent); grades oesophagitis (LA classification A-D) and identifies Barrett's oesophagus

🏆 Gold standard

•24-hour ambulatory pH monitoring - quantifies acid exposure; reserved for pre-surgical workup / non-responders to medical therapy; stop PPI before testing

•Oesophageal manometry - mandatory pre-operative investigation before fundoplication; excludes oesophageal dysmotility (a contraindication to surgery); also used when achalasia is a differential

•H. pylori testing (urea breath test / stool antigen) - if partial PPI response or dyspepsia predominant; must stop PPI ≥2 weeks before urea breath test to avoid false negatives

Differential diagnosis

Key differentials
ConditionDistinguishing featuresKey investigation/treatment
AchalasiaDysphagia to solids AND liquids equally, regurgitation of undigested food, halitosis; NOT caused by GORDManometry (absent peristalsis, failed LOS relaxation); Heller cardiomyotomy
Oesophageal cancerProgressive dysphagia (solids → liquids), weight loss, odynophagia; barium swallow shows irregular stricture with proximal shoulderingUrgent OGD (2-week wait); adenocarcinoma most common in UK (lower third/GOJ)
Laryngopharyngeal refluxGlobus, hoarseness, chronic cough without classic heartburn ('silent reflux'); erythema on laryngoscopy; ~10% of ENT referralsLifestyle + omeprazole
Globus hystericusSensation of lump in throat; completely normal examination AND laryngoscopy (no erythema - unlike LPR)Reassurance
Peptic ulcer diseaseEpigastric pain related to meals; H. pylori positive in mostOGD; H. pylori eradication

Condition	Distinguishing features	Key investigation/treatment
Achalasia	Dysphagia to solids AND liquids equally, regurgitation of undigested food, halitosis; NOT caused by GORD	Manometry (absent peristalsis, failed LOS relaxation); Heller cardiomyotomy
Oesophageal cancer	Progressive dysphagia (solids → liquids), weight loss, odynophagia; barium swallow shows irregular stricture with proximal shouldering	Urgent OGD (2-week wait); adenocarcinoma most common in UK (lower third/GOJ)
Laryngopharyngeal reflux	Globus, hoarseness, chronic cough without classic heartburn ('silent reflux'); erythema on laryngoscopy; ~10% of ENT referrals	Lifestyle + omeprazole
Globus hystericus	Sensation of lump in throat; completely normal examination AND laryngoscopy (no erythema - unlike LPR)	Reassurance
Peptic ulcer disease	Epigastric pain related to meals; H. pylori positive in most	OGD; H. pylori eradication

Management

•Step 1 - Lifestyle: weight loss, smoking cessation, reduce alcohol, avoid late meals, elevate bed head

•First-line pharmacological: omeprazole 20 mg once daily (or any PPI) for 1 month - for uninvestigated dyspepsia/GORD without red flags

•If PPI trial fails: switch to H. pylori test-and-treat (do NOT simply double the PPI dose or switch PPI brand)

•H. pylori eradication (if positive): 7-day triple therapy - omeprazole + amoxicillin + clarithromycin; confirm eradication with urea breath test ≥4 weeks after completing antibiotics

•If no response to PPI: offer H2-receptor antagonist (e.g. ranitidine) as second-line

•Surgery - laparoscopic Nissen fundoplication: for refractory GORD, patient unwilling to take long-term medication, or complications (e.g. recurrent aspiration pneumonia); requires pre-operative manometry and 24-hour pH monitoring

🎯
NICE strategy for uninvestigated dyspepsia: offer either a 1-month full-dose PPI OR H. pylori test-and-treat first. If the first strategy fails, switch to the other - do not escalate within the same strategy.

Complications

•Reflux oesophagitis - mucosal inflammation; graded A-D (LA classification) on OGD

•Benign peptic stricture - fibrotic narrowing from repeated inflammation; presents as progressive dysphagia; treated with endoscopic dilatation

•Barrett's oesophagus - metaplastic replacement of squamous with columnar (intestinal-type) epithelium in the distal oesophagus; premalignant; requires endoscopic surveillance

•Oesophageal adenocarcinoma - arises from Barrett's via progressive dysplasia; most common oesophageal cancer in the UK; distal third / GOJ; risk factors: male sex, obesity, smoking, untreated GORD

•Iron-deficiency anaemia - chronic occult blood loss from erosive oesophagitis

•Aspiration pneumonia - recurrent microaspiration; an indication for surgical anti-reflux therapy

⚠️
Achalasia is NOT a complication of GORD. It is a primary oesophageal motility disorder (autoimmune destruction of inhibitory myenteric neurones) causing failure of LOS relaxation and absent peristalsis - essentially the opposite problem to GORD. Treated surgically with Heller cardiomyotomy.

Paediatric GORD

•In infants: milky vomits after feeds + crying/irritability during feeds - most likely diagnosis is gastro-oesophageal reflux

•Risk factors: preterm delivery

•Distinguish from cow's milk protein allergy (formula-fed, diarrhoea, atopy) and duodenal atresia (bilious vomiting in neonates)