Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Gastro-oesophageal reflux disease and hiatus hernia
Essential points for quick revision.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
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Volvulus or strangulated paraoesophageal hernia
Severe chest or epigastric pain, persistent retching, inability to swallow or pass a nasogastric tube, shock or peritonism may indicate acute gastric volvulus and ischaemia.
Action: Resuscitate, keep nil by mouth, obtain urgent CT and senior upper-GI surgical input, and decompress the stomach only with appropriate expertise because blind force may perforate distorted anatomy.
Synopsis
Diagnose and treat acid reflux while separating sliding from paraoesophageal hernia, investigate alarm features, and select physiological testing or surgery for persistent anatomically important disease.
Typical GORD causes heartburn and acid regurgitation, but response to a PPI does not exclude cancer or prove reflux is the only diagnosis.
A sliding hiatus hernia moves the gastro-oesophageal junction above the diaphragm and promotes reflux; a paraoesophageal hernia can obstruct or volvulise without dominant heartburn.
For uncomplicated GORD use a full-dose PPI for four or eight weeks, then the lowest dose that controls symptoms. Severe oesophagitis needs eight weeks of the severe full dose and long-term full-dose maintenance rather than routine step-down.
Key red flags
Dysphagia, weight loss, haematemesis, melaena, anaemia or persistent vomiting requires endoscopic or cancer-pathway assessment rather than repeated acid suppression.
Sudden pain and retching in a known large paraoesophageal hernia suggests volvulus or strangulation and needs emergency surgical review.
Mucosal alarm
Progressive dysphagia, bleeding, anaemia and weight loss are not reasons simply to double a PPI; they require endoscopic assessment.
Investigation priorities
01
Upper-GI endoscopyFirst step
Assess alarm symptoms, mucosal injury and visible hernia anatomy.
Management branches
AcuteTreat possible gastric volvulus
A patient with a large paraoesophageal hernia develops severe chest pain, repeated dry retching and shock.
Begin ABCDE resuscitation, keep nil by mouth and call upper-GI surgery and anaesthesia immediately.
Obtain urgent contrast CT if sufficiently stable to define rotation, perfusion and perforation.
Key medicines
OmeprazoleFor uncomplicated adult GORD, give omeprazole 20 mg orally once daily, preferably before food, for four weeks and continue to eight weeks if needed. For severe reflux oesophagitis, give 40 mg once daily for eight weeks and continue long-term full-dose 40 mg once daily after healing; reserve symptom-led reduction to the lowest controlling dose for uncomplicated disease.Swallow the gastro-resistant tablet whole with water; do not chew or crush it. Nelfinavir is contraindicated and concomitant clopidogrel is discouraged. Investigate alarm symptoms before empirical treatment, review interacting medicines and long-term magnesium, vitamin B12, infection and fracture risks in context, and consider a lower dose in hepatic impairment rather than applying a universal maximum.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.