Gastro-Oesophageal Reflux Disease (GORD)
NICE CKS Dyspepsia – proven GORD. Last revised: Jul 2023.
NICE Clinical guideline [CG184] Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Last updated: Oct 2019.
Background information added accordingly. Minor changes and enhancements are made to the diagnosis and management section.
Date: 23/11/25
Background Information
Definition
GORD is defined as the reflux of gastric contents (esp. acid, bile and pepsin) back into the oesophagus, causing symptoms of heartburn and acid regurgitation
Aetiology
Organic causes of GORD:
- Upper GI structural disorders
- LOS dysfunction
- Hiatus hernia
- Oesophageal strictures
- Oesophageal / gastric cancer
- Oesophageal motility disorders (e.g. achalasia) (see the Oesophageal Motility Disorders article)
Risk factors of GORD can be categorised based on the underlying mechanisms:
| ↓ Tone of LOS |
|
| ↑ Intra-gastric pressure |
|
| Delayed gastric emptying |
|
Note that H. pylori infection is NOT a risk factor for GORD. In fact, it reduces the risk of developing GORD. [Ref]
Diagnosis
Clinical Features
Typical presentation:
- Cardinal symptoms of recurrent heartburn (burning, retrosternal chest pain) + regurgitation
- Symptoms are often worse after:
- Lying down (esp. going into bed soon after dinner) (patients may report sleeping on multiple pillows to improve symptoms)
- Eating certain foods / beverage (e.g. alcohol, coffee, fatty meal, chocolate)
Other features:
- Chronic cough
- Hoarseness
- Laryngitis, pharyngitis
- Dental erosions
- Belching
- Dysphagia, odynophagia
- Respiratory conditions
- Laryngitis, pharyngitis
- Asthma exacerbation
- Idiopathic pulmonary fibrosis
Red Flags for Upper GI Malignancy
Offer urgent upper gastrointestinal endoscopy if:
- Dysphagia alone, or
- ≥55 y/o with weight loss and any of the following:
- Upper abdominal pain
- Reflux
- Dyspepsia
Other less commonly examined red flags:
- Consider a suspected cancer pathway referral for people with an upper abdominal mass consistent with stomach cancer
- Consider non-urgent direct access upper gastrointestinal endoscopy in people with haematemesis
- Consider non-urgent direct access upper gastrointestinal endoscopy in ≥55 y/o with:
- Treatment-resistant dyspepsia, or
- Upper abdominal pain with low haemoglobin levels, or
- Raised platelet count with any of the following:
- Nausea
- Vomiting
- Weight loss
- Reflux
- Dyspepsia
- Upper abdominal pain, or
- Nausea or vomiting with any of the following:
- Weight loss
- Reflux
- Dyspepsia
- Upper abdominal pain
Investigation and Diagnosis
GORD is primarily a clinical diagnosis
Only offer upper GI endoscopy if there are red flag symptom(s) (see above) or refractory symptoms. There are 2 possible endoscopic diagnoses:
- Oesophagitis: presence of oesophageal inflammation and mucosal erosions
- Endoscopy-negative reflux disease (non-erosive reflux disease): normal endoscopic appearance but the person has typical GORD features
Further investigations (NOT routinely performed, mainly for endoscopy-negative reflux disease): [Ref]
- 24-hour oesophageal pH monitoring – gold standard
- Excessively high acid exposure time on pH monitoring is diagnostic of GORD
- Barium swallow / meal (to exclude structural disorders or motility disorders)
- Oesophageal manometry (to exclude oesophageal motility disorder)
Routine H. pylori testing is NOT recommended in those with typical GORD presentation.
Management
Conservative / General Management
For all patients:
| Medication review | Important drugs to look out for:
|
| General lifestyle advice |
|
| Prevent triggers / attacks |
|
Primary Care Management
1st line: full-dose PPI for 4 weeks (or 8 weeks if there is severe oesophagitis)
2nd line (for persistent or recurrent symptoms), consider one of the following based on clinical judgement:
- Further course of full-dose PPI / switch to an alternative PPI / increase to double dose
- Adding or switching to a H2-receptor antagonist (e.g. ranitidine, famotidine, nizatidine) at bedtime (esp. if there are nocturnal symptoms)
- Long-term maintenance treatment with PPI
In the context of proven GORD, do NOT offer H. pylori test and treat. As H. pylori is associated with peptic ulcer disease, not GORD. In fact, it decreases the risk of developing GORD [Ref]
Regarding long-term treatment with PPI, advise:
- Long-term PPI is not routinely recommended
- Use the lowest effective dose to control symptoms
- If possible, step down or stop treatment
- Consider self-treatment with antacid and/or alginate therapy, although not recommended for long-term or continuous use
Key long-term complications of PPI use:
- Risk of infections – C. difficile infection, pneumonia
- Electrolyte deficiencies – hyponatraemia, hypomagnesaemia
- Malabsorption – iron deficiency, risk of osteoporosis (from impaired calcium absorption)
- GI effects – rebound acid hypersecretion when stopped suddenly, hypergastrinaemia → fundic gland polyps
Secondary Care Management
Consider laparoscopic fundoplication – the gold standard anti-reflux surgery
- Fundoplication involves wrapping the gastric fundus around the lower oesophagus to reinforce the LOS, creating a functional barrier to prevent acid reflux
References