PassFinals
Gastroenterology & Nutrition

Gastro-oesophageal Reflux Disease

Reflux of gastric contents across an ineffective gastro-oesophageal barrier causes troublesome symptoms or mucosal injury; the clinical priority is to recognise alarm features, treat typical disease safely, and investigate persistent or unexplained symptoms objectively.

In a nutshell

Recognise typical post-prandial heartburn and regurgitation, but triage alarm features and cardiac mimics first. Treat uncomplicated GORD with targeted self-care and a full-dose PPI, then step down; investigate persistent or unexplained symptoms objectively and reserve surgery for confirmed reflux after specialist assessment.

Classic presentation

Retrosternal burning and acid regurgitation, worse after meals or when supine, sometimes with a sour taste or waterbrash.

Key points

  • The core problem is reflux across the gastro-oesophageal barrier, not necessarily excess acid production.
  • Heartburn and regurgitation are typical; cough and hoarseness are non-specific and need alternative causes considered.
  • Dysphagia is an alarm feature that bypasses routine empirical management and needs the suspected cancer referral pathway.
  • Treat typical GORD with a full-dose PPI, then use the lowest effective or as-needed regimen when safe.
  • A PPI response supports treatment but does not prove GORD or exclude structural disease.
  • Do not routinely perform endoscopy solely to look for Barrett's; use risk, symptoms, severity and specialist guidance.
  • Objective reflux monitoring and manometry are specialist tests, especially before antireflux surgery.

First-line investigation

Clinical assessment and medicine review for typical symptoms without alarm features; arrange OGD or an urgent referral pathway when red flags or persistent unexplained symptoms are present.

Management

Triage danger and alarm features

  • Assess acute or exertional chest pain for cardiac disease; refer dysphagia and the current NICE weight-loss/reflux combination through the suspected cancer pathway, and urgently assess bleeding, persistent vomiting or severe systemic illness.1,5,3

Confirm the clinical pattern

  • For typical heartburn or regurgitation without alarm features, review medicines, comorbidity, posture, meal timing and individual triggers; do not treat cough or hoarseness as GORD without considering alternatives.1,2,3

Treat uncomplicated symptoms

  • Offer targeted lifestyle advice, short-term antacid or alginate relief when appropriate, and a full-dose PPI course for four or eight weeks according to severity and response.1,2,3,7

Step down and review

  • When symptoms recur, use the lowest PPI dose that controls them and discuss as-needed use; review long-term treatment regularly, with sustained full-dose therapy for severe oesophagitis or a dilated oesophageal stricture when indicated.1,7

Investigate treatment failure

  • Persistent, unexplained or treatment-resistant symptoms need specialist review, OGD with biopsies or reflux and motility testing as indicated; use the H. pylori pathway only when dyspepsia testing is appropriate and observe the PPI washout requirement.1,2,4

Manage complications and surgery safely

  • Manage severe oesophagitis, stricture and confirmed Barrett's through specialist follow-up; consider fundoplication only for confirmed acid reflux after objective reflux and motility assessment, especially when long-term medication is unwanted or not tolerated.1,6,4

Exam traps

  • Do not label acute or exertional chest pain as reflux until a cardiac cause has been considered.
  • Do not describe dysphagia as a minor reflux symptom: it changes the referral pathway.
  • Do not call a PPI response diagnostic; reflux monitoring may be needed when the diagnosis remains uncertain.
  • Do not use routine blanket food restriction; target individual triggers and avoid treatment that causes unnecessary nutritional burden.
  • Do not send a person straight to fundoplication without confirmed reflux and specialist motility and reflux assessment.

Illustrations

Mechanism of the gastro-oesophageal barrierDiagram contrasting a competent gastro-oesophageal junction with transient sphincter relaxation and hiatus hernia, showing how gastric contents can reflux into the oesophagus.PassFinals · original
Reflux oesophagitis with strictureEndoscopic view of severe reflux oesophagitis with circumferential mucosal inflammation, ulceration and narrowing of the distal oesophageal lumen.melvil, Wikimedia Commons · CC-BY-SA-4.0
Barrett's oesophagusEndoscopic and histological representation of columnar metaplasia replacing distal oesophageal squamous mucosa; interpretation requires endoscopy and histopathology.Samir, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE CG184, Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and managementUpdated 18 Oct 2019
  2. NICE CKS, Gastro-oesophageal reflux disease
  3. NHS, heartburn and acid refluxUpdated 20 Nov 2023
  4. British Society of Gastroenterology, guidelines for oesophageal manometry and reflux monitoring
  5. NICE NG12, Suspected cancer: recognition and referralUpdated 15 Apr 2026
  6. NICE NG231, Barrett's oesophagus and stage 1 oesophageal adenocarcinomaUpdated 2 Nov 2022
  7. BNF, omeprazole

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.