Gastro-oesophageal reflux disease (GORD)

Management of Gastro-oesophageal reflux disease (GORD) in primary care after clinical diagnosis or after endoscopic confirmation after having been through the dyspepsia guideline.

  • GORD includes endoscopy-negative reflux disease (like functional dyspepsia but with a predominance of reflux symptoms), oesophagitis, oesophageal ulcers or benign oesophageal strictures
  • There is no evidence to support H. pylori testing in patients with GORD

Excluded from Clinical Referral Guideline

  • Pregnancy-associated dyspepsia
  • Patients under 18 years old

Assessment

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

Investigations

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

Management

Consider the following:
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:

Referral

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:

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

Supporting Information

Pathway Group

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

Publication date: August 2015

 

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