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.
Definition
Gastro-oesophageal reflux disease is troublesome symptoms or mucosal damage caused by reflux of gastric contents into the oesophagus, commonly heartburn and acid regurgitation, with or without endoscopically visible oesophagitis.
Epidemiology
GORD is common. Risk is associated with factors including obesity, hiatus hernia, pregnancy, smoking and medicines or foods that provoke symptoms in an individual.
Pathophysiology
Reflux results from failure or transient relaxation of the gastro-oesophageal barrier, sometimes with hiatus hernia or increased intra-abdominal pressure. Acid and other gastric contents irritate oesophageal sensory pathways and mucosa; repeated injury may cause oesophagitis, peptic stricture or Barrett's metaplasia.
First principles
GORD is reflux disease, not simply excess acid
Transient lower oesophageal sphincter relaxations, a hypotensive sphincter, hiatus hernia and raised intra-abdominal pressure can allow gastric contents to move into the oesophagus. Acid suppression reduces injury and symptoms, but the underlying problem is the reflux barrier and exposure pattern rather than necessarily excessive acid production.1,2,3
The typical symptom pattern follows anatomy and gravity
Heartburn and acid regurgitation are commonly worse after eating, when bending forward or lying down. Symptoms may be extra-oesophageal, such as cough or hoarseness, but these features are non-specific and should not be attributed to GORD without considering respiratory, ENT, cardiac and other causes.1,2,3
A PPI response supports treatment but does not prove the diagnosis
A clinical diagnosis and empirical PPI trial are reasonable for typical reflux-like symptoms without alarm features. Improvement is not a definitive diagnostic test, and persistent or unexplained symptoms need reassessment rather than indefinite escalation of acid suppression.1,2,4
Alarm features change the pathway
Dysphagia, weight loss with reflux in the relevant NICE referral population, gastrointestinal bleeding, persistent vomiting, anaemia or treatment-resistant symptoms may indicate structural disease or malignancy. These findings require an appropriate urgent or direct-access investigation pathway rather than reassurance from a PPI response.1,5,3
Barrett's oesophagus is a specialist diagnosis
Chronic reflux can be associated with Barrett's oesophagus, but routine endoscopy solely to look for Barrett's is not recommended. Consider endoscopy according to GORD severity, symptoms, risk factors and patient preference; confirmed Barrett's requires histological assessment and specialist surveillance decisions.1,6
Presentation
Heartburn or acid regurgitation, often post-prandial and worse when supine or bending forward, with possible atypical cough or hoarseness; severe or persistent symptoms may be complicated by oesophagitis, stricture or Barrett's oesophagus.1,5,3
Cardinal features
- Retrosternal burning discomfort or heartburn
- Acid or food regurgitation and sour taste
- Symptoms worse after eating, lying down or bending forward
- Waterbrash, nausea or upper abdominal discomfort
- Cough, hoarseness or recurrent throat symptoms, which remain non-specific
- Recurrent symptoms after stopping acid suppression
Red flags
- Dysphagia or food sticking: use the suspected cancer referral pathway
- Reflux with weight loss in an adult aged 55 or over
- Haematemesis, melaena or other significant gastrointestinal bleeding
- Persistent vomiting, iron-deficiency anaemia or a concerning examination finding
- Treatment-resistant, persistent or unexplained symptoms
- Acute or exertional chest pain, syncope, breathlessness or autonomic symptoms suggesting a cardiac emergency
Investigations
Clinical assessment and review of medicines
Typical heartburn and regurgitation without alarm features can usually be managed initially as reflux-like dyspepsia. Assess timing, posture, response to treatment, pregnancy where relevant, and medicines that may cause dyspepsia or oesophageal injury; consider cardiac, biliary, peptic, respiratory and functional alternatives.
Expected finding: A symptom pattern compatible with reflux and no alarm feature; a mismatch or concerning feature should prompt a different pathway rather than diagnostic certainty.
1,2,3Upper gastrointestinal endoscopy with biopsy when indicated
OGD directly assesses oesophagitis, ulceration, peptic stricture, Barrett's oesophagus, malignancy and alternative diagnoses. It is indicated through the relevant alarm-feature or suspected-cancer pathway, and is appropriate in persistent, unexplained or treatment-resistant symptoms after clinical review.
Expected finding: Normal mucosa, reflux oesophagitis, peptic stricture, Barrett's mucosa, eosinophilic oesophagitis or another structural lesion; a normal OGD does not by itself exclude reflux disease.
1,5,2,6Helicobacter pylori breath or stool-antigen testing
Use H. pylori test-and-treat when the presentation is managed as uninvestigated dyspepsia or another indication exists; it is not a substitute for investigating GORD alarm features. Stop PPI treatment for the guideline washout period before a breath or stool-antigen test, using clinical judgement about symptom control and alternative medicines.
Expected finding: A reliable positive or negative result that informs eradication treatment and the dyspepsia pathway.
1,2Ambulatory oesophageal reflux monitoring
pH or pH-impedance monitoring is a specialist test when the diagnosis remains uncertain, symptoms persist despite optimised treatment, or objective reflux evidence is needed before surgery. Choose testing on or off PPI according to the clinical question and specialist protocol.
Expected finding: Objective acid or non-acid reflux burden and symptom association; a normal study should prompt consideration of reflux hypersensitivity, functional symptoms or another diagnosis.
4,2High-resolution oesophageal manometry
Manometry assesses motility when dysphagia or a motility disorder is suspected and is required before antireflux surgery to characterise oesophageal motor function and exclude a major alternative such as achalasia.
Expected finding: Normal or abnormal oesophageal motor function that informs specialist diagnosis and treatment selection; manometry is not a routine first-line test for uncomplicated typical GORD.
4,1Management
| Step | Detail | Source |
|---|---|---|
| Triage chest pain and alarm features first | Assess acute or exertional chest pain for a cardiac cause and use emergency pathways when indicated. Dysphagia requires a suspected cancer pathway referral; reflux with weight loss in an adult aged 55 or over also meets the current NICE oesophageal-cancer referral combination. Significant bleeding, persistent vomiting, anaemia, severe systemic illness or a concerning examination requires urgent clinical assessment rather than empirical reassurance.1,5,3 | NICE CG184, NICE NG12 and NHS heartburn and acid-reflux safety-netting |
| Offer targeted lifestyle and self-care advice | Support weight reduction when overweight, smoking cessation, smaller meals and avoidance of individual triggers. Avoid eating shortly before bed, reduce excess alcohol, and consider raising the head of the bed for nocturnal symptoms; do not advise blanket exclusion of every potential trigger if it is not relevant to the individual. Antacids or alginates can help short-term symptoms but should not be used regularly for prolonged periods without review.1,2,3 | NICE CG184, NICE CKS and NHS heartburn and acid-reflux advice |
| Treat typical GORD with a full-dose PPI | For GORD, offer a full-dose PPI for four or eight weeks according to severity and response, taking account of comorbidity, interactions, patient preference and the current BNF entry for the selected PPI. A treatment response supports symptom control but should not obscure later alarm features or an alternative diagnosis.1,7,2 | NICE CG184 recommendations 1.6.1 to 1.6.2 and BNF omeprazole |
| Step down after control and review ongoing need | If symptoms recur after initial treatment, use the lowest PPI dose that controls symptoms and discuss as-needed use where appropriate. Review long-term treatment regularly, including the indication, adherence, interactions and whether step-down or stopping is safe. People with severe oesophagitis or a dilated oesophageal stricture generally need long-term full-dose PPI treatment under the guideline pathway.1,7 | NICE CG184 recommendations 1.5.1, 1.6.3, 1.6.4, 1.6.6 and 1.6.9 |
| Manage inadequate PPI response deliberately | Check the diagnosis, adherence, timing, interactions, ongoing triggers and whether treatment has been optimised before escalating. NICE allows H2-receptor-antagonist therapy when response to a PPI is inadequate; persistent or unexplained symptoms should prompt specialist review and investigation rather than repeated empirical changes without a diagnostic plan.1,2,3 | NICE CG184, NICE CKS and NHS heartburn and acid-reflux guidance |
| Use H. pylori testing only in the correct dyspepsia pathway | When H. pylori test-and-treat is indicated for coexisting or uninvestigated dyspepsia, allow a two-week PPI washout before breath or stool-antigen testing and follow current eradication guidance. Do not delay urgent endoscopy or cancer referral while pursuing a test-and-treat strategy for alarm features.1,2 | NICE CG184 and NICE CKS |
| Refer persistent, unexplained or treatment-resistant symptoms | Refer to a specialist service when symptoms are non-responsive, persistent or unexplained after initial assessment, or when the person is considering surgery. Specialist assessment may include OGD with biopsies, reflux monitoring, manometry, assessment for eosinophilic oesophagitis or another diagnosis, and review of non-GORD causes of cough, hoarseness or chest pain.1,2,4 | NICE CG184 recommendation 1.11.1 and BSG reflux-monitoring guidance |
| Manage severe oesophagitis, stricture and Barrett's through specialist follow-up | Use the NICE severe-oesophagitis pathway, including healing treatment and long-term maintenance when indicated. After stricture dilatation, continue long-term full-dose PPI under NICE guidance. Do not routinely scope solely to diagnose Barrett's; if Barrett's is confirmed by endoscopy and histopathology, base surveillance and dysplasia management on specialist NICE guidance, risk and patient preference.1,6,2 | NICE CG184 and NICE NG231 |
| Consider antireflux surgery only after objective specialist assessment | Consider laparoscopic fundoplication for confirmed acid reflux when symptoms are controlled by acid suppression but the person does not want long-term treatment, or cannot tolerate it. Confirm the diagnosis and assess motility and reflux objectively before surgery; discuss benefits, risks, alternatives and the possibility that surgery will not treat symptoms caused by another mechanism.1,4 | NICE CG184 recommendation 1.10.1 and BSG reflux-monitoring guidance |
Illustrations
Differentials
Acute coronary syndrome or other cardiac chest pain
Exertional or pressure-like pain, radiation, autonomic symptoms, breathlessness or cardiovascular risk; manage as potentially cardiac until assessed.
Peptic ulcer disease or dyspepsia
Epigastric pain, NSAID exposure or H. pylori association; follow the dyspepsia and ulcer pathway.
Eosinophilic oesophagitis
Dysphagia or food bolus obstruction, often with atopy; requires OGD biopsies even when mucosa looks normal.
Achalasia or other oesophageal motility disorder
Progressive dysphagia to solids and liquids, regurgitation or weight loss; specialist endoscopy and manometry are required.
Oesophageal or gastric malignancy
Progressive dysphagia, weight loss, bleeding, anaemia, vomiting or treatment-resistant symptoms; follow NICE referral guidance.
Functional heartburn or reflux hypersensitivity
Persistent symptoms with no objective reflux or structural explanation; specialist reflux monitoring and symptom correlation may clarify the diagnosis.
Complications
- Reflux oesophagitis and ulceration
- Peptic oesophageal stricture and dysphagia
- Barrett's oesophagus with dysplasia or adenocarcinoma risk
- Extra-oesophageal symptoms such as cough or hoarseness, with other causes needing assessment
- Recurrent symptoms and treatment burden
Prognosis
Most people with uncomplicated GORD respond to acid suppression, but symptoms commonly recur and require a reviewed lowest-effective or as-needed regimen. Severe oesophagitis, stricture, Barrett's oesophagus, alarm features and persistent unexplained symptoms require specialist follow-up or a different diagnostic pathway.
Guidelines
- Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184) (NICE, 2014)
- Suspected cancer: recognition and referral (NG12) (NICE, 2015)
- Guidelines for oesophageal manometry and reflux monitoring (British Society of Gastroenterology, 2019)
References
- NICE CG184, Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and managementUpdated 18 Oct 2019
- NICE CKS, Gastro-oesophageal reflux disease
- NHS, heartburn and acid refluxUpdated 20 Nov 2023
- British Society of Gastroenterology, guidelines for oesophageal manometry and reflux monitoring
- NICE NG12, Suspected cancer: recognition and referralUpdated 15 Apr 2026
- NICE NG231, Barrett's oesophagus and stage 1 oesophageal adenocarcinomaUpdated 2 Nov 2022
- BNF, omeprazole
Evidence checked: 2026-08-03
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.