Gastro Oesophageal Reflux Disease



·         Will run 26th January to 22nd February 2015

·         Main message is ‘Having heartburn, most days, for 3 weeks or more could be a sign of cancer – tell your doctor.’

·         It is not well communicated but the TARGET GROUP IS PATIENTS AGE > 50

The RMS reflux guidelines have changed slightly to be consistent with the new NICE dyspepsia guidelines from September 2014 and are set out below.

Usually reflux alone for 3 weeks is not an indication for referral however the RMS will be relaxed about rejecting referrals for reflux in those over age 50 (agreed with RCH gastro consultant body Jan 2015)

Patients under 50 need to follow the guidance below strictly please




Typical GORD symptoms are above the diaphragm featuring heartburn, sour taste, belching or regurgitation which are common 2 hours after a fatty / large volume meal

General points

  • Despite the fact that chronic reflux is a risk factor for Barrett’s oesophagus which in turn is a risk factor for oesophageal adenocarcinoma, neither NICE [1] nor the British Society of Gastroenterology advocate referral for chronic reflux unless:
    • Primary care management doesn’t control symptoms and patient would accept OGD
    • The patient is on long term PPIs but would prefer surgical therapy (laparoscopic fundoplication)
    • Alarm (2 week wait) features
  • The majority of cases of reflux can be treated in primary care
  • Success of anti-reflux treatment is a reasonable diagnostic test in primary care
  • Helicobacter eradication is not indicated for GORD (despite NICE guidelines suggesting that it should be – they group GORD and dyspepsia together which is an oversimplification)

Primary care treatment– in summary:       

  • Review medications particularly
    • Calcium antagonists
    • Nitrates
    • Theophylline
    • Bisphosphonates should be stopped immediately
  • Lifestyle advice
    • Weight optimisation / exercise / minimise alcohol / stop smoking / certain foodstuffs as a trigger / over the counter alginate or ranitidine therapy
    • Patient education and reassurance – information leaflet here
      • CBT is a recognised treatment option
    • 4-8 week trial full dose PPI 30 minutes before food then stop and review
    • Step up / step down approach
      • Step 0- lifestyle advice as described above +/- over the counter treatments (alginates / ranitidine)
      • Step 1– continue PPI (ensure 30-60mins before food) at lowest dose to control symptoms or use when required
      • Step 2- maximise PPI dose or try different PPI
      • Step 3 - add ranitidine (max 300mg per day) +/- alginates
      • Step 4- consider referral to upper GI surgeon for consideration of anti-reflux surgery

NBRebound hyperacidity: there may be a worsening of reflux symptoms for a few weeks after discontinuation of PPI which the patient should be warned about

NB – DOMPERIDONE has a safety warning from the MHRA issued in April 2014. The only indication now is for relief of nausea and vomiting and for a week maximum and at a dose not exceeding 30mg per day. This is because of concerns of cardiac side effects. It is contraindicated in those with a cardiac history. 


Perform 6-12 month medication reviews to try to step down

Possible risks of long term PPI use:

·         Epidemiological evidence of modest increase in fracture predominantly in the elderly (consider other risks for osteoporosis and treat accordingly) [3]

·         Controversial observational evidence of increased risk of c-difficile diarrhoea and pneumonia

Referral criteria

  • Primary care management doesn’t control symptoms and the patient would accept OGD
  • The patient is on long term PPIs but would prefer surgical therapy (laparoscopic fundoplication)

·         Alarm (2 week wait) features

·         Have a lower threshold for referral if the patient has a history of Barrett’s oesophagus or a family history of upper GI cancer [2]

Referral is most appropriate to the upper GI surgeons for consideration of anti-reflux surgery 

Information to include in the referral

  • Please detail which of the above primary care treatments have failed

Upper GI red flags/2ww criteria:

Refer for direct access gastroscopy:   

  • Dysphagia
  • Aged 55 or over with weight loss AND any of the following:
    • Reflux
    • Abdominal pain
    • Dyspepsia

Refer to the upper GI 2ww service:

  • Ultrasound indicates gall bladder cancer
  • CT indicates pancreatic cancer
  • Ultrasound indicates pancreatic cancer
  • Upper abdominal mass consistent with gastric cancer
  • Any patient with jaundice
  • Aged 60 or over with weight loss AND any of the following:
    • Diarrhoea
    • Back pain
    • Abdominal pain
    • Nausea
    • Vomiting
    • Constipation
    • New onset diabetes


[1] NICE clinical guideline 184 (September 2014) here

[2] BMJ 10 minute consultation - Dyspepsia - 2011;343:d6234 available here

[3] MHRA Drug Safety Update April 2012, vol 5 issue 9: A2 here

[4] Gastroenterology consultant working group, Royal Cornwall Hospital