Gastro-Oesophageal Reflux (GORD/GERD) ✅

🔥 Gastro-oesophageal reflux disease (GORD) occurs when gastric contents reflux into the oesophagus causing troublesome symptoms or complications. 👉 Classic symptoms = heartburn and acid regurgitation. ⚠️ Long-standing reflux may lead to erosive oesophagitis, peptic strictures, or Barrett’s oesophagus (a premalignant condition associated with oesophageal adenocarcinoma).

🧾 Aetiology

• Transient lower oesophageal sphincter (LOS) relaxation → most common mechanism.
• Hiatus hernia → disrupts the normal pressure barrier between stomach and oesophagus.
• Reduced LOS tone or impaired oesophageal clearance.
• Delayed gastric emptying may increase reflux episodes.
• Repeated exposure of the oesophageal mucosa to acid and pepsin causes inflammation and mucosal injury.

⚠️ Risk Factors

• 👨 Increasing age, male sex.
• ⚖️ Obesity (↑ intra-abdominal pressure).
• 🤰 Pregnancy.
• 🍺 Alcohol and 🚬 smoking.
• 💊 Drugs reducing LOS tone: nitrates, calcium-channel blockers, tricyclic antidepressants, theophylline.
• Systemic conditions: scleroderma, diabetes with autonomic neuropathy (gastroparesis).

🧬 Pathophysiology

• Transient LOS relaxations allow reflux of gastric contents.
• Acid and pepsin damage squamous epithelium → inflammation and erosions.
• Chronic injury may cause intestinal metaplasia (Barrett’s oesophagus).
• Fibrosis from chronic inflammation can produce peptic strictures leading to dysphagia.

🚨 Complications

• Erosive oesophagitis → pain, bleeding, ulceration.
• Peptic oesophageal stricture → progressive dysphagia.
• Barrett’s oesophagus → intestinal metaplasia of the distal oesophagus.
• Small increased risk of oesophageal adenocarcinoma.

🩺 Clinical Features

• 🔥 Heartburn: retrosternal burning discomfort, worse after meals or lying flat.
• 💧 Acid regurgitation into the mouth or throat.
• 🤢 Water brash: hypersalivation triggered by reflux.
• 🌙 Symptoms often worse at night or after large meals.
• 🫁 Extra-oesophageal symptoms: chronic cough, hoarseness, laryngitis, asthma exacerbation.
• ❗ Chest pain may mimic angina — cardiac causes must be considered.

🔎 Investigations

• In patients with typical symptoms and no alarm features, investigation is usually not required initially.
• 📷 Upper GI endoscopy (OGD) indicated if alarm features are present or symptoms persist despite treatment.
• 📈 24-hour oesophageal pH monitoring used in refractory or atypical cases.
• 🧪 Blood tests are not routine but may be done if anaemia or complications are suspected.

🩻 Differential Diagnoses

• ❤️ Cardiac causes: angina or myocardial infarction.
• 🫀 Biliary disease: biliary colic, cholecystitis.
• 🫁 Respiratory causes: asthma or chronic cough syndromes.
• 🍽️ Functional dyspepsia.

🚩 Red Flags (Require Urgent Endoscopy / Referral)

• 🍽️ Dysphagia or odynophagia.
• 🩸 Gastrointestinal bleeding (haematemesis or melaena).
• 📉 Unintentional weight loss.
• Persistent vomiting.
• Iron-deficiency anaemia.
• New dyspepsia in people ≥55 years.

💊 Management (NICE Approach)

• 🌱 Lifestyle measures:
  • Weight loss if overweight.
  • Avoid late meals and large fatty meals.
  • Reduce alcohol and smoking.
  • Raise head of bed if nocturnal symptoms.
• 💊 Drug treatment:
  • Proton pump inhibitor (PPI) first-line (e.g. omeprazole 20 mg OD) for 4–8 weeks.
  • If symptoms resolve → step down to lowest effective dose or on-demand therapy.
  • Antacids or alginates (e.g. Gaviscon) may provide symptomatic relief.
  • H2-receptor antagonists (e.g. famotidine) can be used if PPIs are not tolerated.
• 🧫 H. pylori testing: recommended in uninvestigated dyspepsia rather than typical reflux symptoms.
• 🔪 Surgery: laparoscopic Nissen fundoplication may be considered for severe or refractory GORD despite optimal medical therapy.

📚 References

• NICE: Gastro-oesophageal reflux disease and dyspepsia in adults (CG184)
• NICE: Suspected cancer recognition and referral (NG12)

💡 Clinical Pearls: • Most GORD is diagnosed clinically. • A 4–8 week PPI trial is both diagnostic and therapeutic. • Always screen for alarm symptoms 🚩 which mandate endoscopy. • Barrett’s oesophagus results from chronic acid injury and requires surveillance due to cancer risk.