Diagnosis

• GORD refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease

Investigation

• n/a

Management

Conservative

• Community Pharmacist should offer help for OTC dyspepsia treatments & lifestyle modification
• Lifestyle: Diet, weight reduction, smoking cessation
• Avoid known precipitants: Alcohol, fatty food, smoking, coffee, chocolate
• Psychotherapy / CBT may reduce symptoms in the short term in some people

Referral for Endoscopy

• Review medications causing dyspepsia: NSAID; Bisphosphonates; Theophyllines, Corticosteroids
• Dyspepsia with acute bleeding: refer to specialist – see CG141, if no new symptoms since last endoscopy continue with previous recommendations

Treating Un-investigated Dyspepsia & ‘Reflux like’ symptoms

• Offer PPI therapy for 4 weeks, and H. Pylori ‘test and treat’ to people with dyspepsia (triple therapy)
• Allow 2 weeks to wash out before testing for H. Pylori with breath test (C13) or stool antigen, re-testing with breathe test only
• H2 receptor antagonist if there is an inadequate response to PPI
• If symptoms return after initial care step down to minimum dose to control symptoms

GORD Treatment

• Full dose PPI for 4-8 weeks
• If symptoms return after initial care step down to minimum dose to control symptoms
• H2 receptor antagonist if there is an inadequate response to PPI
• If stricture dilatation then remain on full dose PPI
• Consider endoscopy to diagnose Barrett’s if patient has GORD, but not routinely

Severe Oesophagitis

• Full dose PPI for 8 wks
• If not controlled symptoms switch to another full dose PPI, and continue at full dose if required

Peptic Ulcer Disease

• Offer H. Pylori eradication triple therapy if test positive for H. Pylori, and have peptic ulcer disease
• Stop NSAIDs if diagnose peptic ulcer disease (Endoscopy) and treat with PPI or H2RA for 8 wks
• Offer repeat endoscopy and testing at 6-8 wks
• Review need for NSAIDs at least every 6 mths and trial ‘as-needed’, if req’d consider COX-2 selective
• If ulcers persist consider non-adherence, malignancy, continued NSAID use or rarely Zollinger Ellison

Functional (Idiopathic) Dyspepsia

• Offer eradication to those testing positive for H. Pylori
• Discuss PPI on an ‘as needed’ basis, avoiding long term ant-acid therapy

H. Pylori Eradication

• Offer PPI, Amoxicillin, Metronidazole or Clarithromicin for 7 days BD (Pen allergic use Clarithromicin and Metronidazole), repeat for a second time if required, then refer is not successful

Laparoscopic Fundoplication

• Consider for those with confirmed diagnosis of acid reflux, and adequate control with acid suppression therapy but do want to continue or cannot tolerate
• If Barrett’s oesophagus diagnoses, offer endoscopic surveillance for cancer progression

NICE Source: CG184 Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Summary compiled by Dr D P Sheppard MBBS.