PPIs are more potent at acid suppression than H 2-receptor antagonists. This provides a degree of diagnostic confirmation and, in the case of suboptimal response, determines whether further investigation is required.įig Approach to management of gastro-oesophageal reflux disease If symptoms persist despite simple measures, and significantly interfere with quality of life, a trial of a PPI is appropriate ( Fig). These treatments may be continued if they are effective, often with the addition of lifestyle modifications. Many patients try over-the-counter medicines such as antacids or H 2-receptor antagonists before they visit a doctor. 10 Drugs with anticholinergic or smooth muscle-relaxing properties may exacerbate reflux symptoms, as may drugs causing a chemical oesophagitis (e.g. Cessation of tobacco and alcohol are recommended but, while this may help some patients, it has not been shown to improve symptoms overall. 10 While routine global elimination of specific food groups triggering reflux is not recommended, patients should avoid foods that specifically trigger their symptoms. Other lifestyle modifications include elevation of the head of the bed and avoidance of meals 2–3 hours before bedtime if there are nocturnal symptoms. 3 A reduction in the body mass index of 3.5 kg/m 2 can result in nearly a 40% reduction in the risk of having frequent symptoms. Of the non-pharmacological approaches to the management of GORD, weight loss has been shown to have a dose-dependent association with reduction of symptoms. Helicobacter pylori eradication is not effective in reducing the symptoms of GORD. Helicobacter pylori infection does not cause GORD and actually appears to be slightly protective against it, Barrett’s oesophagus and oesophageal adenocarcinoma. 13, 14 Usually a specialist consultation is needed. These studies are only required in a minority of patients who are either refractory to treatment or are being assessed for surgery. Findings of gastro-oesophageal reflux induced by position or abdominal pressure are neither sensitive nor specific for GORD. There is no role for the barium swallow in the routine diagnosis of GORD. 12 However, it may have a role in high-risk groups such as the overweight and Caucasian males over 50 years old with no previous endoscopic investigation. 11 There is no evidence that routine screening for Barrett’s oesophagus improves mortality or is cost-effective. Biopsy may be needed to exclude eosinophilic oesophagitis. in overweight men over 50 years, however evidence that screening improves outcomes is lacking)Įosinophilic oesophagitis should be considered in patients, particularly men, in their 20s and 30s with a history of food allergy or atopy who present with dysphagia or refractory symptoms suggestive of GORD. Screening for Barrett’s oesophagus in high-risk patients (may be considered, e.g. Treatment of complications such as dilatation of oesophageal stricturesĮvaluation of patients before and after anti-reflux surgical procedures Persistent symptoms despite an adequate trial of proton pump inhibitor therapy Indications for gastroscopy in gastro-oesophageal reflux disease 9 4 The correlation between symptoms and the severity of oesophagitis is weak, but if typical features are present without ‘red flags’ ( Box 1) 9 then there is no need for gastroscopy in the initial assessment and empirical treatment can commence. While several validated symptom-based questionnaires exist, their use is largely limited to research studies. 4 Other non-specific symptoms include vomiting, anorexia, dysphagia, cough and other respiratory or oropharyngeal symptoms. ![]() ![]() Regurgitation is described as the effortless appearance of gastric contents in the throat or mouth without associated nausea or retching. 4 Practitioners need to be aware of this and clarify the nature of the symptoms being discussed when the term is used. Heartburn is described as a burning, retrosternal, rising sensation associated with meals, although this definition is often poorly understood by the general population. The presence of either symptom has an overall sensitivity of 49% and specificity of 74%. A presumptive diagnosis of GORD can be made based on the typical symptoms of heartburn and regurgitation.
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