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Used as 1st line treatment/before investigation

omeprazole

omeprazole/sodium bicarbonate

esomeprazole

rabeprazole

pantoprazole

lansoprazole

dexlansoprazole

------> higher dose and further testing if incomplete response

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1st Test:
- trial proton-pump inhibitor for 8 weeks

Investigations to Consider if no improvement on PPI, or alarming symptoms:

-Oesophagogastroduodenoscopy

endoscopy for oesophagus, stomach, duodenum

-Ambulatory pH Monitoring

Wireless radiotelemetry capsule or naso-oesophageal catheter monitor abnormal presence of oesophageal acid

(pH < 4 for more than 4% of the time abnormal)

- Combined impedance-pH testing

Similar to Ambulatory pH monitoring, but catheter senses acid and non-acid presence in oesophagus for 24 hr period

Recommended for patients who have heartburn or regurgitation that has not responded to twice daily PPIs

-Oesophageal capsule endoscopy

Involves swallowing a capsule endoscope to visualise oesophagus.

Less invasive than upper endoscopy, can show oesophagitis or Barrett's oesophagus, but only moderate sensitivity/limited role

- Oesophageal manometry

evaluates oesophageal contractions and lower oesophageal function

UK guidelines recommend manometry performed prior to anti-reflux surgery

https://bestpractice.bmj.com/topics/en-gb/82/investigations

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- Heartburn (esacerbated by bending and lying down, food and alcohol)
- Waterbrash
- Acid Brash
- Helped by taking Antacids (Rennie & Gaviscon)

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- Smoking (30 pack years)
- Alcohol intake (over 20 units per week)
- Over Weight (BMI of 29.5)
- Taking NSAIDs (200mg Ibuprofen) regularly

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H. Pylori association with GORD is controversial, but eradication may help symptoms.

First line of treatment must be used before testing for and treating H.Pylori

Testing for H.Pylori involves The Urea 13C breath test (Blow into breath test bag after swallowing a urea and radioactive / non radioactive carbon isotope)

Stool Helicobacter Antigen Test (SAT) (STOOL SAMPLE)

https://www.nice.org.uk/guidance/cg184/chapter/Introduction

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- Lower Oesophageal Sphincter Hypotension
- Hiatus Hernia
- Oesophageal Dysmotility (e.g. systemic sclerosis)
- Obesity
- Gastric Acid Hypersecretion
- Delayed Gastric Emptying
- Smoking
- Alcohol
- Pregnancy
- Drugs (Tricyclics, anticholinergics, nitrates)
- Helicobacter pylori

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Wilkinson, I B, Raine, T, Wiles, K, Goodhart, A, Hall, C, O'Neil, H. (2017). Oxford Handbook of Clinical Medicine. 10th ed. Oxford: Oxford University Press. p.254.

Gastro Medicine and Endoscopy (GME). (2020). Gastro - Oesophageal Reflux Disease GORD. [Online]. GME. Available at: https://www.gastromedicine.com.au/gastro-oesophageal-reflux-disease-gord/ [Accessed 4 October 2022].

National Institute for Health & Care Excellence. (2014). Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. [Online]. NICE. Last Updated: 19th October 2019. Available at: https://www.nice.org.uk/guidance/cg184/chapter/Introduction [Accessed 4 October 2022].

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+ve Symptoms include;

Oesophageal:

- Heartburn;  (burning, retrosternal discomfort after meals, lying, stooping or straining , relieved by antacids)
- Belching; Acid brash (acid or bile regurgitation) water brash (increase in saliva in the mouth
-Odynophagia; (painful swallowing e.g. from oesophagitis or ulceration

Extra-Oesophageal:

- Nocturnal Asthma
- Chronic Cough
- Laryngitis
- Sinusitis