Gastro-oesophageal reflux disease (GORD)

Signs and Symptoms

Gastro-oesophageal reflux disease (GORD) symptoms include those found in dyspepsia together with regurgitation

Differential Diagnoses

• Check for features suggestive of cardiac pain eg:
  • Association with exercise
  • Radiation to arm
• Musculoskeletal pain

GORD:

• Can be diagnosed clinically, symptoms include those found in dyspepsia together with regurgitation
• Found on OGD for investigation of dyspepsia in 40% of cases, having been managed by the appropriate pathway

Consider the following:

• Antacids and alginates produce rapid but short-term symptom relief (see 1.1 Dyspepsia and gastro-oesophageal reflux disease)

Consider the impact of the following:

• Concurrent disorder, e.g. irritable bowel syndrome (IBS)
• Psychological, social, and lifestyle issues

Clinical Management GORD or Endoscopy-negative reflux disease (reflux symptoms with normal scope):

• Treat with full dose PPI for 4 weeks (omeprazole 20mg or lansoprazole 30mg daily)
• If no response then try H₂ receptor agonist (H₂RA) for 4 weeks
• If no response consider referral
• Once responded to PPI or H₂RA then continue low dose maintenance or as required treatment and annual review
• See 1.3 Antisecretory drugs and mucosal protectants

Non-severe oesophagitis:

• Full dose PPI for 4 or 8 weeks (omeprazole 20mg or lansoprazole 30mg daily)
• If no response, double dose of PPI for 1 month
• If still no response then swap to H₂RA for 1 month
• If still no response, consider referral
• Once responded to a treatment then swap to a low dose maintenance or as required PPI or H₂RA and annual review
• See 1.3 Antisecretory drugs and mucosal protectants

Severe oesophagitis including oesophageal ulcers:

• PPI for 8 weeks according to BNF guidance (local formulary guidance is omeprazole 40mg daily)
• if ongoing symptoms, double the dose of the original PPI or switch to full dose or high dose different PPI for 8 weeks. if symptoms still persist refer
• If symptoms resolve, continue long term continuous PPI and review at least annually
• For relapse, consider switching to a different PPI and if not responding consider referral
• See 1.3 Antisecretory drugs and mucosal protectants

Benign oesophageal stricture:

• These patients need long term continuous PPI (omeprazole 20mg/ lansoprazole 30mg)
• If there is a recurrence, they may benefit from twice daily PPI, seek specialist advice
• See 1.3 Antisecretory drugs and mucosal protectants

Referral Criteria

Endoscopy-negative reflux disease (reflux symptoms with normal scope) or clinical GORD:

• Treat with full dose PPI (omeprazole 20mg or lansoprazole 30mg daily) for 4 weeks
• If no response then try H₂RA for 4 weeks
• If no response consider referral
• Once responded to PPI or H₂RA then continue low dose maintenance or as required treatment and annual review
• See 1.3 Antisecretory drugs and mucosal protectants

Non-severe oesophagitis:

• Full dose PPI (omeprazole 20mg or lansoprazole 30mg daily) for 4 or 8 weeks
• If no response, double dose of PPI for 1 month
• If still no response then swap to H₂RA for 1 month
• If still no response, consider referral
• Once responded to a treatment then swap to a low dose maintenance or as required PPI or H₂RA and annual review
• See 1.3 Antisecretory drugs and mucosal protectants

Severe oesophagitis including oesophageal ulcers:

• Full dose PPI (omeprazole 20mg or lansoprazole 30mg daily) for 8 weeks
• If ongoing symptoms, double the dose of the original PPI or switch to full dose or high dose different PPI for 8 weeks. if symptoms still persist refer
• If symptoms resolve, continue long term continuous full dose PPI and review at least annually
• For relapse, consider switching to a different PPI at full or double dose and if not responding consider referral
• See 1.3 Antisecretory drugs and mucosal protectants

Benign oesophageal stricture:

• These patients need long term continuous full dose PPI
• If there is a recurrence, they may benefit from twice daily PPI, seek specialist advice
• See 1.3 Antisecretory drugs and mucosal protectants

Referral Instructions

Refer to Gastroenterology

• Refer using e-Referral Service:
  • Specialty: GI and Liver (Medicine and Surgery)
  • Clinic Type: Upper GI
  • Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N

Refer for Endoscopy

• Refer using e-Referral Service:
  • Specialty: GI and Liver (Medicine and Surgery)
  • Clinic Type: Endoscopy
  • Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N

Referral Forms

DRSS Referral Proforma

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: August 2015