GORD (Acid Reflux): Symptoms, When to Scope and Treatment

Gastro-oesophageal reflux disease (GORD, also called GERD) is a condition in which stomach contents flow back into the oesophagus often enough to cause troublesome symptoms or complications. Heartburn is very common, and most people can be managed in primary care with lifestyle changes and acid suppression.

Causes and risk factors

• A weak or relaxed lower oesophageal sphincter.
• Hiatus hernia.
• Obesity.
• Pregnancy.
• Smoking and alcohol.
• Large, fatty or late-night meals.
• Some drugs, for example calcium channel blockers, nitrates, anticholinergics and theophylline.

Clinical features

Typical symptoms:

• Heartburn: a burning feeling rising behind the breastbone, often after meals or when lying down.
• Regurgitation of acid or food into the mouth.

Other features:

• an acid taste in the mouth
• epigastric pain
• chronic cough
• hoarseness
• worsening asthma
• dental erosion

Cardiac chest pain can feel like heartburn. Consider cardiac causes in at-risk patients.

When to investigate

Many patients are treated without tests. Upper GI endoscopy is indicated for:

• alarm features:
  • difficulty swallowing
  • weight loss
  • GI bleeding or anaemia
  • persistent vomiting
  • an abdominal mass
• older patients with new symptoms
• symptoms that do not respond to treatment
• assessment for Barrett's oesophagus in patients at risk

Oesophageal pH or impedance monitoring and manometry are used before surgery, or when the diagnosis is uncertain.

Management

Lifestyle

• Lose weight if overweight.
• Stop smoking.
• Reduce alcohol.
• Eat smaller meals and avoid eating within 3 hours of bedtime.
• Raise the head of the bed if symptoms are worse at night.
• Avoid foods that trigger symptoms.

Medicines

• Antacids and alginates for occasional symptoms.
• Proton pump inhibitors (PPIs), for example omeprazole, are the most effective treatment. They are usually taken 30–60 minutes before breakfast for 4–8 weeks, then reduced to the lowest effective dose or used "on demand".
• H2 receptor antagonists, for example famotidine, are an alternative or add-on.
• Test for and treat H. pylori in dyspepsia according to local guidance.

Surgery

Laparoscopic fundoplication is an option for selected patients with confirmed reflux who do not respond to, or do not want, long-term medication.

Long-term PPI use

PPIs are generally safe, but long-term use has been associated with:

• low magnesium
• low vitamin B12
• an increased risk of Clostridioides difficile infection
• possibly fractures

Review the need for them regularly.

Complications

• Oesophagitis.
• Peptic stricture, causing difficulty swallowing.
• Barrett's oesophagus: the normal squamous lining is replaced by columnar cells. It is a precancerous change that increases the risk of oesophageal adenocarcinoma and needs surveillance endoscopy.

Exam pearls

• Difficulty swallowing is an alarm symptom. Refer for urgent endoscopy.
• Barrett's oesophagus leads to adenocarcinoma, not squamous cell carcinoma.
• Always consider a cardiac cause of "heartburn" in patients with risk factors.

For more, see Exam Night Notes 1.0: Gastro Surgery and the Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Which symptom is an alarm feature needing urgent endoscopy?

   1. Difficulty swallowing
   2. Regurgitation at night
   3. Heartburn after meals
   4. Acid taste
   5. Bloating
   Show answer

   Answer: A. Difficulty swallowing
   Dysphagia, weight loss, GI bleeding, anaemia and persistent vomiting are alarm features.

2. Barrett's oesophagus increases the risk of:

   1. Squamous cell carcinoma
   2. Gastric lymphoma
   3. Adenocarcinoma of the oesophagus
   4. Hiatus hernia
   5. Achalasia
   Show answer

   Answer: C. Adenocarcinoma of the oesophagus
   Columnar metaplasia in Barrett's oesophagus predisposes to adenocarcinoma.

3. Best timing for a once-daily PPI:

   1. Only when pain is severe
   2. At bedtime with food
   3. 30–60 minutes before breakfast
   4. After lunch
   5. With antacids
   Show answer

   Answer: C. 30–60 minutes before breakfast
   PPIs work best before the first meal, when proton pumps are activated.

4. Which is a recognised effect of long-term PPI use?

   1. Hypermagnesaemia
   2. Low magnesium and low vitamin B12
   3. Hyperkalaemia
   4. Weight loss
   5. Thrombocytosis
   Show answer

   Answer: B. Low magnesium and low vitamin B12
   Long-term PPIs are associated with hypomagnesaemia, B12 deficiency and C. difficile infection.

5. Which surgical procedure treats refractory reflux?

   1. Pyloroplasty
   2. Gastrectomy
   3. Whipple's procedure
   4. Heller myotomy
   5. Laparoscopic fundoplication
   Show answer

   Answer: E. Laparoscopic fundoplication
   Fundoplication wraps the fundus around the lower oesophagus to strengthen the barrier.

More articles in Gastroenterology & Hepatology

• Peptic Ulcer Disease and H. pylori: Testing and TreatmentCauses of peptic ulcers, alarm features, H. pylori breath and stool tests, eradication regimens, PPI healing and ulcer complications.
• Hepatitis B: Transmission, Serology and TreatmentHepatitis B explained: how it spreads, interpreting HBsAg, anti-HBs and anti-HBc, chronic infection, tenofovir/entecavir and birth-dose vaccination.
• Hepatitis C: Testing and Cure with Direct-Acting AntiviralsHepatitis C in Pakistan and beyond: transmission, anti-HCV and HCV RNA testing, sofosbuvir-based cure, follow-up and prevention.
• Liver Cirrhosis: Causes, Child-Pugh Score and ComplicationsCirrhosis explained: causes, signs of chronic liver disease, Child-Pugh and MELD, ascites, SBP, varices, encephalopathy and HCC surveillance.

Browse all 56 articles →

Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.