There is helpful, patient-friendly information and advice to be found on the GI section of the NHS Lothian Internet pages. There are also some videos by our very own GI team which patients have been responding very positively to. Consider sharing the link with patients and/or carers. Please note that although this page is named “Dyspepsia” there is some relevance to GORD patients too.
https://services.nhslothian.scot/GI/Dyspepsia/Pages/default.aspx
Symptoms of GORD:
- Heartburn
- Regurgitation of gastric contents into the mouth
- Waterbrash (excessive salivation)
- Chest pain
Diagnosis
The diagnosis of GORD is usually made on the clinical history. Typically patients will describe retrosternal burning (“heartburn”), often at night or on stooping. The onset of symptoms is frequently associated with weight gain.
Before considering referral for endoscopy / cytosponge
- Undertake medication review to look for drugs which make cause or exacerbate symptoms
- NSAIDs
- Corticosteroids
- Calcium channel antagonists
- Nitrates
- Theophyllines
- Bisphosphonates
- Gallstone or biliary disease (especially if severe, episodic pain)
- Cardiac disease
- Normal endoscopy-treat as Functional dyspepsia
- Previous oesophagitis-treat as GORD/oesophagitis
GORD is very common, affecting up to 20% of the adult population at any given time
Patients usually complain of a combination of
- heartburn (an uncomfortable burning sensation in the chest that often occurs after eating)
- acid reflux (where stomach acid comes back up into your mouth and causes an unpleasant, sour taste)
- bloating and belching
- nausea and/or vomiting
Referral for further tests is seldom necessary in younger patients
- See Primary Care Management for those aged <55 years
However, AGE (55 years or over) is an important determinant of pathology
Consider urgent referral if any combination of the following in a patient 55 years old or over
- upper abdominal pain or reflux
- unexplained weight loss
- anaemia (if >55 yrs and in the presence of GI symptoms, this need not be true iron deficiency)
Guidelines for referral for endoscopy-Urgent-suspected cancer
Dysphagia
- interference of the swallowing mechanism at any age OR
Odynophagia
- pain on swallowing at any age
New onset upper gastrointestinal pain or discomfort (>55 yrs)
New or worsening upper gastrointestinal pain or discomfort combined with one or more of the following features (any age):
- unexplained weight loss
- unexplained iron deficiency anaemia
- Persistent vomiting more than 4 weeks
Upper gastrointestinal pain or discomfort combined with one of following risk factors (any age):
- family history of oesophago-gastric cancer in more than two first-degree relatives
- family history of familial adenomatous polyposis in any first-degree relative
- Barrett’s oesophagus
- pernicious anaemia
- gastric surgery over 20 years ago
- known dysplasia, atrophic gastritis or intestinal metaplasia
In the absence of alarm symptoms in those aged <55 years
Consider lifestyle measures
- Achieve and maintain healthy weight, avoid food triggers, avoid smoking, avoid eating or drinking for 3hr before bed.
Trial of alginates as required
Treat with full dose PPI (omeprazole 20mg od or equivalent) for 4 weeks
- If symptoms recur offer ongoing PPI therapy but step down treatment to lowest effective dose
- Discuss use of “as required” treatment to encourage self- management of symptoms
- Offer an H2RA (ranitidine 150mg bd) if inadequate response to PPI (this can be added in at bedtime in addition to PPI therapy if required)
- Offer annual review to assess symptom control and reduce or withdraw treatment if possible
Special considerations
Previous oesophageal stricture dilatation
- remain on long term full dose PPI
Endoscopically diagnosed severe oesophagitis
- offer full dose PPI for 8 weeks
- if no healing consider
- High dose PPI (eg omeprazole 40mg daily)
- Switch to another PPI at full dose or high dose
- Offer long term maintenance full dose PPI
- Switch to another PPI at full or high dose if initial PPI fails to control symptoms
Barrett’s oesophagus
