Approach

Diagnosis is clinical, supported by testing when required. Patients should be queried about the frequency, severity, timing (day time or night time), and duration of symptoms and the presence of any specific triggers (dietary or non-dietary).[5]​ Heartburn and regurgitation are the most reliable symptoms.[1] These often occur after meals, especially large or fatty meals. Symptoms may be worse when the patient is lying down or bending over. Relief with antacids is typical. Extra-oesophageal symptoms include cough, laryngitis, asthma, or dental erosion.[1][6]

Alarm symptoms (anaemia, dysphagia, haematemesis, melaena, persistent vomiting, or involuntary weight loss) raise the possibility of oesophagitis, peptic stricture, or cancer.[9]

Physical examination is generally normal.

While typical patients may be given a therapeutic trial of proton-pump inhibitors (PPIs), those with long-standing or alarm symptoms warrant additional investigation. Those who do not respond to PPIs also merit further evaluation for complications or other conditions.

Routine testing for Helicobacter pylori is not recommended by most guidelines. However, in the UK, guidelines from the National Institute for Health and Care Excellence (NICE) recommend offering Helicobacter pylori testing (using a breath test or a stool antigen test) to people with uninvestigated ‘reflux-like’ symptoms (i.e., people with ‘reflux-like’ symptoms who have not had an endoscopy).[36]​​

Typical symptoms

A short trial (about 8 weeks) of a PPI and lifestyle therapy (such as weight loss if needed, and elevation of head of bed for nocturnal features) should be started in patients with typical symptoms, namely heartburn and regurgitation.[1][37]

Symptom relief is presumed to be diagnostic, but failure of PPI treatment does not exclude GORD.

Using endoscopy and ambulatory pH monitoring as a reference standard, a short trial of high-dose PPI has a pooled sensitivity of 78% and specificity of 54%.[1]

Endoscopy for longstanding, unresponsive, or atypical symptoms

Upper endoscopy (oesophagogastroduodenoscopy, OGD) is indicated in patients with atypical, relapsing, or persistent symptoms.[1][5][37][38]​​​​ OGD may identify an alternative diagnosis (such as oesophageal malignancy or peptic ulcer) or identify complications of GORD (such as Barrett's oesophagus).

Consider evaluation for non-gastrointestinal causes before endoscopy in patients with isolated extra-oesophageal features (e.g., laryngitis, globus, tooth enamel erosion, halitosis).[6]​ Patients who have extra-oesophageal features with typical GORD symptoms may have an initial 8-12 week trial of PPI therapy before endoscopy or further testing.[1][6]

If endoscopy is performed to diagnose GORD, PPI therapy should be withheld for 2-4 weeks to assess whether there is excessive oesophageal acid exposure in the absence of a PPI.[1]

Barrett's oesophagus may be found after healing of higher grades of erosive oesophagitis. Thus, if endoscopy is performed because of concern for Barrett's oesophagus (e.g., long-standing symptoms), it may be best to carry out the procedure after an 8-week course of PPI treatment.[38]

Alarm signs and symptoms

Alarm signs and symptoms that suggest complicated disease include weight loss, dysphagia, odynophagia, anaemia, bleeding, or evidence of blood in stool.[1][9]​ These patients warrant endoscopy. [Figure caption and citation for the preceding image starts]: Moderate to severe oesophagitis with multiple linear, clean-based oesophageal ulcersFrom the collection of Dr Douglas G. Adler; used with permission [Citation ends].com.bmj.content.model.Caption@53605ae0

Patients with persistent symptoms on therapy with PPIs

Further testing is warranted in patients with persistent symptoms despite PPI therapy. Endoscopy should be performed, if not performed previously.[1][37]

In the absence of erosive oesophagitis (Los Angeles grade B and above) or long-segment Barrett's oesophagus (≥3 cm), prolonged ambulatory pH monitoring should be performed, off drug therapy, to confirm or rule out GORD.[37]

Oesophageal manometry should be performed:[1]

  • before anti-reflux surgery;

  • in patients unresponsive to PPIs where an aetiology cannot be determined using impedance-pH monitoring;

  • and in patients with non-cardiac chest pain, especially those unresponsive to PPIs, to assess for motility abnormalities.

Other imaging modalities

Oesophageal capsule endoscopy is a less-invasive, safe alternative to upper endoscopy, and a potential screening and diagnostic tool to evaluate oesophageal pathology. Studies have shown only moderate sensitivity and specificity for diagnosis of oesophageal disorders, and it has a limited role and acceptance in screening for mucosal disease (erosive oesophagitis and Barrett's oesophagus).[39][40][41] Capsule endoscopy is done for patient convenience in select circumstances. It is contraindicated in the presence of suspected (e.g., presence of dysphagia) or known stricture or adhesions.

Barium swallow may be useful in patients with dysphagia for whom endoscopy is contraindicated or unavailable.[42][43] Barium imaging should not be used solely as a diagnostic test for GORD.[1] The presence of reflux on a barium oesophagram has poor sensitivity and specificity for GORD, compared with pH testing.[1]

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