Gastro-oesophageal Reflux Disease
A failure of the lower oesophageal sphincter barrier lets acid reflux into an oesophagus not built to tolerate it, so the symptom pattern follows directly from where and how often that acid tracks backwards.
In a nutshell
A weak or overwhelmed lower oesophageal sphincter lets normally-secreted acid reflux into acid-intolerant squamous mucosa. Symptoms are predictable from posture and timing, atypical presentations follow acid reaching the pharynx or airway, and chronic exposure can remodel the lining into premalignant Barrett's epithelium.
Classic presentation
Retrosternal burning worse after meals and on lying flat or bending forward, with regurgitation, relieved by antacids and improving with a PPI trial.
Key points
- The primary defect is a failing barrier (transient LOS relaxation, hiatus hernia, raised intra-abdominal pressure), not excess acid secretion.
- Symptom timing (post-prandial, worse supine) follows directly from gastric distension and gravity, not memorisation.
- Extra-oesophageal symptoms (cough, hoarseness, nocturnal wheeze) arise from acid reaching the pharynx and airway or vagal reflexes.
- Barrett's oesophagus is an adaptive metaplastic response to chronic acid injury and carries malignant potential.
- Alarm features (dysphagia, weight loss, bleeding, anaemia, age over 55 with new symptoms) mandate endoscopy, not an empirical PPI trial.
First-line investigation
In typical symptoms without alarm features, an empirical PPI trial; endoscopy is reserved for alarm features or refractory disease.
First-line management
Lifestyle modification alongside a full-dose PPI trial, stepping down to the lowest effective dose once symptoms are controlled.
Exam traps
- Any dysphagia, at any age, bypasses empirical treatment and goes straight to endoscopy.
- Chest pain attributed to reflux must first have cardiac causes excluded: the mechanisms can mimic each other clinically.
- A good response to a PPI trial supports but does not prove the diagnosis, and does not exclude Barrett's if alarm features later develop.
Educational content pending clinical review. Not medical advice.