AKT · Gastroenterology/Oesophagus & stomach

GORD & Barrett oesophagus

Reflux of gastric contents through an incompetent lower oesophageal sphincter

Overview

Gastro-oesophageal reflux disease — symptomatic reflux of acid through an incompetent lower oesophageal sphincter, causing heartburn and regurgitation. Managed with lifestyle change and a full-dose PPI. Chronic reflux can cause Barrett oesophagus (intestinal metaplasia — a pre-malignant change needing surveillance). The key skill is recognising ALARM features that mandate endoscopy.

Recognise

Burning retrosternal discomfort (heartburn) and acid regurgitation, worse lying down/after meals/bending
Waterbrash, nocturnal cough, hoarseness, dental erosion; often overweight/smoker, hiatus hernia
Barrett: columnar (intestinal) metaplasia at the lower oesophagus on endoscopy — pre-malignant (adenocarcinoma risk), needs surveillance

Red flags

ALARM features → urgent endoscopy: Anaemia (iron-deficiency), Loss of weight, Anorexia, Recent-onset/progressive symptoms, Melaena/haematemesis, Swallowing difficulty (dysphagia)
Dysphagia or age ≥55 with weight loss + upper abdominal pain/reflux/dyspepsia → 2-week-wait endoscopy

Differentials & how to tell them apart

Peptic ulcer diseaseepigastric pain related to meals; H. pylori/NSAID-related; endoscopy/biopsy

Oesophageal cancerprogressive dysphagia + weight loss — ALARM, urgent endoscopy

Cardiac chest pain (ACS)exertional, radiating, with cardiovascular risk — exclude first if any doubt

Achalasia / eosinophilic oesophagitisdysphagia for solids and liquids / food bolus in young atopic — manometry/biopsy

Barrett oesophagus — salmon-pink columnar metaplasia at the lower oesophagus (endoscopy)
Samir / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Clinical diagnosis. Endoscopy (OGD) for ALARM features/refractory symptoms (oesophagitis grade, Barrett, exclude cancer). Do NOT test for H. pylori in proven GORD. 24-h pH/manometry pre-surgery.

Management

Lifestyle + full-dose PPI (4 weeks; 8 weeks if severe oesophagitis)

1Lifestyle measures (weight loss, smoking cessation, trigger avoidance) + full-dose PPI for 4 weeks (8 weeks for severe oesophagitis), then long-term maintenance PPI. Review medications that worsen reflux.Gate: Do NOT test for H. pylori in PROVEN GORD; ANY ALARM feature (dysphagia, weight loss, anaemia, GI bleeding, or age ≥55 with persistent symptoms) → urgent endoscopy, not just a PPI trial
2Refractory/complicated → endoscopy, optimise PPI, consider fundoplication. Barrett → surveillance endoscopy ± radiofrequency ablation for dysplasia.

Lifestyle (weight loss, smoking cessation, avoid triggers, raise bed-head) — first-line; weight loss + stopping smoking have the best evidence

Full-dose PPI (e.g. omeprazole) — 4 weeks (8 weeks for severe oesophagitis), then maintenance; review drugs that worsen reflux

H2-receptor antagonist / alginate — alternative/adjunct symptom relief

Key points

Heartburn + regurgitation = GORD → lifestyle + PPI; don't H. pylori-test proven GORD. The whole skill is spotting ALARM features (dysphagia/weight loss/anaemia/bleeding) for urgent endoscopy. Barrett's (metaplasia) is the pre-malignant sequel.

Monitor & prognosis

Symptom response; Barrett surveillance; deprescribe/step-down PPI where possible.

Good; small adenocarcinoma risk via Barrett.

Source: NICE NG (GORD/dyspepsia); CKS Dyspepsia – proven GORD