Gastro-Oesophageal Reflux Disease (GORD)
PPI therapy, Barrett's oesophagus surveillance and anti-reflux surgery per NICE CG184
GORD is caused by failure of the lower oesophageal sphincter, allowing gastric acid to reflux into the oesophagus. It affects approximately 20% of the UK adult population. Complications include erosive oesophagitis, oesophageal stricture, and Barrett's oesophagus — a pre-malignant condition requiring endoscopic surveillance.
Diagnosis and Alarm Features
GORD is typically a clinical diagnosis in patients with classic heartburn and regurgitation — no investigation is required before an empirical PPI trial. Endoscopy is indicated for: alarm features (dysphagia, weight loss, anaemia, haematemesis); failure of PPI therapy; to assess for Barrett's oesophagus or stricture; and for patients over 55 with new unexplained symptoms. 24-hour pH monitoring or pH-impedance study is the gold standard for confirming GORD when endoscopy is normal and symptoms are atypical. Atypical presentations include chronic cough, laryngitis, asthma exacerbation, and dental erosion.
PPI and Medical Management
Standard-dose PPI is first-line: omeprazole 20 mg once daily, lansoprazole 30 mg once daily, or equivalent — taken 30 minutes before breakfast. A double dose (omeprazole 40 mg) is used for erosive oesophagitis or inadequate response. Treatment duration is 4–8 weeks; long-term therapy at the lowest effective dose is appropriate for frequent relapsing GORD. Alginate preparations (Gaviscon Advance 10–20 mL after meals and at bedtime) are useful as adjuncts for breakthrough symptoms. Famotidine 20 mg twice daily is an alternative H2 antagonist for mild or intermittent GORD or nocturnal acid breakthrough.
Barrett's Oesophagus and Surgery
Barrett's oesophagus — metaplastic change from squamous to columnar epithelium — is found in approximately 10% of patients undergoing endoscopy for GORD. It carries a small but significant risk of progression to oesophageal adenocarcinoma. Surveillance endoscopy intervals: no dysplasia every 3–5 years; low-grade dysplasia every 6–12 months or endoscopic ablation. High-grade dysplasia requires radiofrequency ablation (RFA) or endoscopic mucosal resection. Anti-reflux surgery (laparoscopic Nissen fundoplication or LINX device) is offered after full investigation (pH study and manometry) for confirmed GORD where the patient prefers to avoid long-term PPI or has failed medical management.