Synopsis
Diagnose and treat gastro-oesophageal reflux pragmatically, recognise alarm features and confirm pathological reflux before invasive or prolonged escalation of therapy.
- GORD occurs when reflux of gastric contents causes troublesome symptoms or complications; heartburn alone is neither necessary nor sufficient for a conclusive diagnosis.
- Typical symptoms are burning retrosternal discomfort and acid regurgitation, often meal-related or worse supine, but chest pain must first be risk-assessed for cardiac disease.
- Dysphagia, weight loss, bleeding, iron-deficiency anaemia, persistent vomiting and an abnormal examination override empirical treatment and prompt urgent investigation.
- For uncomplicated suspected GORD, NICE supports a four- or eight-week course of a full-dose proton pump inhibitor, followed by the lowest dose that controls symptoms.
- Check adherence and timing before declaring PPI failure; a gastro-resistant PPI is generally taken before food according to its product instructions.
- Endoscopy detects erosive oesophagitis, stricture, Barrett mucosa and malignancy, but a normal endoscopy does not exclude reflux disease.
- Ambulatory pH or pH-impedance monitoring distinguishes persistent reflux from reflux hypersensitivity and functional heartburn when the answer will change management.
- High-resolution manometry is not a reflux test; it excludes achalasia or a major motor disorder and locates the lower sphincter before selected reflux testing or surgery.
- Lifestyle advice should be individualised: weight reduction when overweight and avoiding personally reproducible late meals or triggers is more credible than a universal prohibition list.
- Antireflux surgery requires objectively supported GORD, appropriate physiology, informed consent and specialist follow-up because dysphagia, gas-bloat and recurrent reflux can occur.
Key red flags
Odynophagia, bleeding, anaemia or dysphagia can reflect severe oesophagitis, ulcer or peptic stricture and requires endoscopic assessment rather than indefinite empirical treatment.
Progressive dysphagia, weight loss, early satiety, haematemesis, iron-deficiency anaemia or persistent vomiting enters the current NICE suspected-cancer pathway according to age and symptom combination.
Pressure-like discomfort with exertion, breathlessness, sweating, radiation or cardiovascular risk must be assessed urgently for myocardial ischaemia even if reflux has occurred before.
Investigation priorities
Separate uncomplicated reflux from urgent structural or systemic disease.
Management branches
Typical heartburn or regurgitation occurs without alarm features or a dangerous chest-pain phenotype.
- Review alarm features, cardiac risk, pregnancy, medicines and symptom pattern; arrange urgent investigation instead of empirical therapy when the assessment is concerning.
- Offer individual weight and meal advice, then use a full-dose PPI for four or eight weeks according to NICE and the selected product instructions.
- Review response, adherence and timing; if controlled, step down to the lowest effective dose or on-demand use when clinically appropriate.
- If symptoms recur frequently or complications exist, agree a longer-term plan with periodic indication, adverse-effect and deprescribing review.