Dr Toni Hazell offers and update on the diagnosis and management of GORD in adults
Gastro-oesophageal reflux disease (GORD) is a complex of symptoms; NICE guidelines, on which much of this module is based, include it in the broader category of dyspepsia. NICE defines dyspepsia as ‘a complex of upper gastrointestinal tract symptoms typically present for four or more weeks, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting’. It is common, experienced by around 40% of adults each year. GORD describes a chronic condition whereby stomach contents reflux into the oesophagus, causing a feeling often described as heartburn.
For those who have clinical GORD and go on to require an endoscopy, around 40% will have findings such as erosions or gastritis; the remainder are said to have ‘endoscopy-negative reflux disease’, or ‘functional/non-ulcer dyspepsia’. As always, the lack of a positive test doesn’t make the symptoms any less real to the patient so it is important to communicate this sensitively.
For the sake of brevity, the term dyspepsia will be used in this article to cover the broad symptom complex.
It is said that 80% of any diagnosis is in the history and GORD is no different. You are looking to do several things: confirm the diagnosis; rule out other benign conditions, rule out alarm features that might make you consider an urgent referral via the two-week wait cancer pathway; and find out if there are any obvious causes that might be amenable to change.
What causes GORD? Risk factors include stress, smoking and alcohol, trigger foods (coffee, chocolate, fatty foods), obesity, pregnancy, family history and a hiatus hernia. GORD can also be a side-effect of drugs, including some antihypertensives, beta blockers, NSAIDs and tricyclic antidepressants. Reducing stress is easier said than done (particularly if the person works in the NHS!) but it is worth exploring, as are other measures, such as offering help with weight, signposting to a stop-smoking clinic and giving advice on trigger foods. Remember that patients who have obesity may have experienced significant weight-related stigma in the past, including from healthcare professionals so always be sensitive. The 5 As of the Canadian obesity guidelines are useful here – the first one is Ask. Ask permission to discuss obesity and if the answer is no, leave the door open for a discussion in the future when the patient is ready.
- GORD is a chronic condition involving a complex of symptoms.
- Risk factors include stress, smoking and alcohol, trigger foods (coffee, chocolate, fatty foods), obesity, pregnancy, family history, hiatus hernia and the side-effects of some drugs including NSAIDs and antihypertensives.
- Patients who are over 55 and have weight loss combined with upper abdominal pain, reflux or dyspepsia should have an endoscopy within two weeks.
- Treatment for H. pylori and lifestyle changes will often be effective, but refractory symptoms despite optimal treatment should prompt retesting for Helicobacter and consideration of referral.
- Long-term use of PPIs can cause problems, and deprescribing should be considered where appropriate.
Dr Toni Hazell is a GP in north London.
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