Gastro-Oesophageal Reflux Disease
Summary
Gastro-oesophageal reflux disease (GORD) is a condition where stomach contents reflux into the oesophagus, causing troublesome symptoms or complications. Classic symptoms include heartburn and acid regurgitation. GORD is extremely common, affecting 10-20% of the population. Diagnosis is usually clinical for typical symptoms. Alarming features warrant endoscopy to exclude malignancy and assess for Barrett's oesophagus. Treatment follows a stepwise approach: lifestyle modifications, antacids, H2 receptor antagonists, and proton pump inhibitors (PPIs). Complications include erosive oesophagitis, stricture, Barrett's oesophagus, and oesophageal adenocarcinoma. Long-term PPI use is effective but requires consideration of potential side effects.
Key Facts
- Definition: Reflux of stomach contents causing troublesome symptoms or complications
- Incidence: 10-20% of Western population; very common
- Demographics: Increases with age; associated with obesity
- Pathognomonic: Heartburn + regurgitation + response to PPI
- Gold Standard Investigation: Clinical diagnosis; OGD if alarm features
- First-line Treatment: Lifestyle modification + PPI
- Prognosis: Chronic relapsing condition; excellent symptom control with PPIs
Clinical Pearls
PPI Timing Pearl: PPIs work best taken 30-60 minutes BEFORE meals - they inhibit active proton pumps stimulated by food.
Barrett's Pearl: Barrett's oesophagus is a premalignant condition. Screening OGD recommended if multiple risk factors: male, white, obesity, chronic GORD greater than 5 years, family history.
Atypical Pearl: Extra-oesophageal GORD presents with chronic cough, laryngitis, asthma, or dental erosions - consider if refractory to usual treatment.
Refractory Pearl: True refractory GORD is uncommon. First check compliance and timing of PPI, then consider OGD, pH monitoring.
De-escalation Pearl: After 4-8 weeks, try stepping down PPI to lowest effective dose or on-demand therapy.
Why This Matters Clinically
GORD is one of the most common GI conditions seen in primary and secondary care. While usually benign, it significantly impacts quality of life and can lead to serious complications. Appropriate investigation of alarm features and rational PPI prescribing are key.
Prevalence
| Population | Prevalence |
|---|---|
| Western countries | 10-20% |
| Asia | 5-10% |
| Symptoms weekly | 20% |
| Daily symptoms | 5-10% |
Risk Factors
| Category | Factors |
|---|---|
| Lifestyle | Obesity (strongest modifiable), smoking, alcohol, large meals, late eating |
| Dietary | Fatty foods, chocolate, caffeine, mint, spicy foods |
| Anatomical | Hiatus hernia |
| Medications | NSAIDs, calcium channel blockers, nitrates, bisphosphonates, anticholinergics |
| Other | Pregnancy, scleroderma, diabetes (gastroparesis) |
Mechanism Overview
Normal Anti-Reflux Mechanisms:
- Lower oesophageal sphincter (LOS) - high-pressure zone
- Diaphragmatic crura reinforcement
- Angle of His (gastro-oesophageal angle)
- Oesophageal peristaltic clearance
- Saliva and bicarbonate neutralisation
GORD Pathophysiology:
Step 1: LOS Dysfunction
- Transient LOS relaxations (most common mechanism)
- Reduced basal LOS pressure
- Hiatus hernia disrupts anti-reflux barrier
Step 2: Reflux of Gastric Contents
- Acid, pepsin, bile reflux into oesophagus
- Prolonged acid exposure
Step 3: Oesophageal Mucosal Injury
- Acid damages oesophageal epithelium
- Inflammation (oesophagitis)
- Symptoms triggered by acid stimulation of sensory nerves
Step 4: Complications (if untreated/severe)
- Erosive oesophagitis
- Stricture formation
- Barrett's metaplasia
- Adenocarcinoma
Hiatus Hernia
- Sliding type (95%): Gastro-oesophageal junction slides above diaphragm
- Rolling/paraoesophageal type (5%): Fundus herniates, GOJ in place
- Contributing factor to GORD, not causative alone
Typical Symptoms
| Symptom | Description |
|---|---|
| Heartburn | Burning retrosternal discomfort, worse after meals, lying down |
| Regurgitation | Acid or bitter taste in mouth |
| Dyspepsia | Upper abdominal discomfort |
| Water brash | Sudden salivation with sour taste |
Atypical/Extra-Oesophageal Symptoms
| Symptom | Mechanism |
|---|---|
| Chronic cough | Microaspiration, vagal reflex |
| Laryngitis | Posterior larynx acid exposure |
| Asthma exacerbation | Vagal bronchospasm, aspiration |
| Dental erosions | Acid damage to enamel |
| Globus sensation | Pharyngeal irritation |
| Chest pain | Non-cardiac, may mimic angina |
Alarm Features (Red Flags)
[!CAUTION]
- Dysphagia (must investigate)
- Odynophagia
- Unintentional weight loss
- GI bleeding (haematemesis, melaena)
- Persistent vomiting
- Iron deficiency anaemia
- Age greater than 55 with new-onset symptoms
- Epigastric mass
Often Normal
- GORD typically has no specific examination findings
May Find
- Epigastric tenderness (non-specific)
- Signs of complications (anaemia, weight loss)
- Dental erosions
Look For
- BMI (obesity is major risk factor)
- Signs of systemic disease (scleroderma - tight skin, telangiectasia)
When to Investigate
| Scenario | Action |
|---|---|
| Typical symptoms, no alarm features, age less than 55 | Empirical PPI trial (diagnostic and therapeutic) |
| Alarm features | Urgent OGD (2-week wait referral) |
| Age greater than 55 with new dyspepsia | OGD to exclude malignancy |
| Refractory symptoms | OGD, consider pH monitoring |
Oesophagogastroduodenoscopy (OGD)
Findings:
| Los Angeles Classification | Severity |
|---|---|
| Grade A | Mucosal breaks less than 5mm |
| Grade B | Mucosal breaks greater than 5mm, non-circumferential |
| Grade C | Circumferential breaks less than 75% |
| Grade D | Circumferential breaks greater than 75% |
- Barrett's oesophagus: Salmon-coloured mucosa (biopsy for intestinal metaplasia)
- Stricture
- Hiatus hernia
pH Monitoring
- 24-hour ambulatory pH monitoring (off PPI)
- pH-impedance monitoring (detects acid and non-acid reflux)
- Indicated for: refractory symptoms, pre-operative assessment, diagnostic uncertainty
Other Tests
| Test | Purpose |
|---|---|
| Oesophageal manometry | Pre-surgical (exclude motility disorder), atypical symptoms |
| Barium swallow | Anatomical assessment of hiatus hernia (rarely used now) |
| H. pylori testing | Consider testing and treating if dyspepsia |
Management Algorithm
GORD SYMPTOMS
↓
┌────────────────────────────────────────────────────────┐
│ ASSESS FOR ALARM FEATURES │
│ Dysphagia, weight loss, bleeding, age greater than 55 │
└────────────────────────────────────────────────────────┘
↓
Alarm Features?
↓ Yes ↓ No
┌──────────────┐ ┌──────────────────────────────────────┐
│ URGENT OGD │ │ LIFESTYLE + EMPIRICAL PPI (4-8 wks) │
└──────────────┘ └──────────────────────────────────────┘
↓
Response to PPI?
↓ Yes ↓ No
┌──────────────┐ ┌──────────────────────────┐
│ Step down to │ │ Check compliance/timing │
│ lowest dose │ │ Double-dose PPI 4 weeks │
│ or on-demand │ │ If still refractory: OGD │
└──────────────┘ └──────────────────────────┘
↓
┌────────────────────────────────┐
│ pH monitoring if OGD normal │
│ Consider anti-reflux surgery │
└────────────────────────────────┘
Lifestyle Modifications
| Modification | Evidence |
|---|---|
| Weight loss (if obese) | Strong evidence |
| Avoid late meals (3hrs before bed) | Moderate |
| Elevate head of bed | Moderate (nocturnal symptoms) |
| Avoid trigger foods | Anecdotal but reasonable |
| Smoking cessation | Weak for GORD, strong overall |
| Reduce alcohol | Weak |
Pharmacotherapy
Step 1: Antacids/Alginates
- Gaviscon, Rennie
- Symptom relief, no healing
Step 2: H2 Receptor Antagonists
- Ranitidine (withdrawn in many countries), famotidine
- Less effective than PPIs
Step 3: Proton Pump Inhibitors (First-line)
| PPI | Dose | Notes |
|---|---|---|
| Omeprazole | 20mg OD | Most commonly used |
| Lansoprazole | 30mg OD | Alternative |
| Esomeprazole | 20-40mg OD | S-isomer of omeprazole |
| Pantoprazole | 40mg OD | Fewer drug interactions |
| Rabeprazole | 20mg OD | Alternative |
PPI Principles:
- Take 30-60 minutes before meals
- Full dose for 4-8 weeks
- Then step down to lowest effective dose
- On-demand therapy suitable for mild GORD
Long-Term PPI Considerations
| Concern | Evidence |
|---|---|
| Hip fracture | Small increased risk, clinically modest |
| C. difficile infection | Small increased risk |
| Hypomagnesaemia | Rare, monitor if on diuretics |
| B12/iron deficiency | Rare |
| Kidney disease | Uncertain association |
| Dementia | Association not confirmed |
Benefits usually outweigh risks for indicated use.
Surgical Options
Laparoscopic Fundoplication (Nissen)
- Wrap gastric fundus around LOS
- Effective for well-selected patients
- Consider if: young, good response to PPI but want to stop, large hiatus hernia
- Complications: dysphagia, bloating, gas-bloat syndrome
LINX Device
- Magnetic sphincter augmentation
- Alternative to fundoplication
| Complication | Incidence | Management |
|---|---|---|
| Erosive oesophagitis | 30-40% of GORD | PPI heals in 80-90% |
| Oesophageal stricture | 5-10% of erosive | Dilation + PPI |
| Barrett's oesophagus | 5-10% of chronic GORD | Surveillance OGD |
| Oesophageal adenocarcinoma | 0.5% per year in Barrett's | Early detection, treatment |
| Bleeding | Rare | Endoscopic therapy |
Barrett's Oesophagus
- Intestinal metaplasia of oesophageal mucosa
- Premalignant condition
- Annual cancer risk: 0.5%
- Surveillance OGD every 2-5 years depending on length and dysplasia
- Ablation if dysplasia
Natural History
- Chronic, relapsing condition
- 80% relapse within 6-12 months of stopping PPI
- Majority well controlled with medical therapy
Quality of Life
- Significant impact if untreated
- Excellent improvement with PPI
Key Guidelines
-
NICE Guideline CG184. Dyspepsia and GORD in adults — 2014 (updated 2019)
-
ACG Clinical Guideline: Treatment of GORD — Katz PO et al. Am J Gastroenterol. 2022
-
BSG Guidelines for Barrett's Oesophagus — Fitzgerald RC et al. Gut. 2014
Key Evidence
PPI Efficacy
- Meta-analyses show PPIs heal erosive oesophagitis in 80-90%
- Superior to H2RAs
PPI Safety
- Overall safe for indicated use
- Risks often overstated in media
What is GORD?
GORD (acid reflux) is when stomach acid flows back up into your food pipe (oesophagus), causing heartburn and other symptoms. It's very common and usually not serious.
What causes it?
The valve between your stomach and food pipe doesn't close properly, allowing acid to escape. Factors like excess weight, certain foods, and lying down after eating can make it worse.
Treatment
- Lifestyle changes: Lose weight if needed, avoid late meals, cut down on triggers
- Medication: Tablets that reduce stomach acid (PPIs) are very effective
- You may need long-term medication, but we aim for the lowest effective dose
When to seek help
- Difficulty swallowing
- Unintentional weight loss
- Vomiting blood or black stools
- Persistent symptoms despite treatment
-
NICE Guideline CG184. Gastro-oesophageal reflux disease and dyspepsia in adults. 2014.
-
Katz PO et al. ACG Clinical Guideline for Diagnosis and Management of GORD. Am J Gastroenterol. 2022;117(1):27-56. PMID: 34807007
-
Fitzgerald RC et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63(1):7-42. PMID: 24165758
-
El-Serag HB et al. Update on the epidemiology of gastro-oesophageal reflux disease. Gut. 2014;63(6):871-880. PMID: 23853213
-
Gyawali CP et al. Modern diagnosis of GERD: the Lyon Consensus. Gut. 2018;67(7):1351-1362. PMID: 29437910
-
Vaezi MF et al. Complications of Proton Pump Inhibitor Therapy. Gastroenterology. 2017;153(1):35-48. PMID: 28528705
Viva Points
"GORD presents with heartburn and regurgitation. Diagnose clinically if typical and no alarms. Alarm features need urgent OGD. Treat with lifestyle + PPI (take before meals). Step down once controlled. Barrett's is premalignant - surveillance indicated. Surgery (fundoplication) for selected patients."
Common Mistakes
- ❌ Not asking about alarm features
- ❌ PPI timing errors (after meals instead of before)
- ❌ Not stepping down PPI after initial treatment
- ❌ Missing Barrett's surveillance
- ❌ Attributing all chest pain to GORD (consider cardiac)
Last Reviewed: 2026-01-01 | MedVellum Editorial Team