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Causes of GORD Let ’ s start with the last one first . What causes GORD ? Risk factors include stress , smoking and alcohol , trigger foods ( coffee , chocolate , fatty foods ), obesity , pregnancy , family history and a hiatus hernia . GORD can also be a side-effect of drugs , including some antihypertensives , beta blockers , NSAIDs and tricyclic antidepressants . Reducing stress is easier said than done ( particularly if the person works in the NHS !) but it is worth exploring , as are other measures , such as offering help with weight , signposting to a stop-smoking clinic and giving advice on trigger foods . Remember that patients who have obesity may have experienced significant weight-related stigma in the past , including from healthcare professionals 4 so always be sensitive . The 5 As of the Canadian obesity guidelines 5 are useful here – the first one is Ask . Ask permission to discuss obesity and if the answer is no , leave the door open for a discussion in the future when the patient is ready .
Diagnosis Moving on to making the diagnosis , the patient may complain of pain in the stomach area ( which they may misinterpret as chest pain ), heartburn or a feeling of acid coming up into the mouth , known as water brash . There may also be nausea or vomiting .
Always ask about symptoms that are suggestive of an upper gastrointestinal ( GI ) tract cancer ; this is important medicolegally and must be recorded in the notes even if the answer is negative . These symptoms include loss of appetite or weight , intractable vomiting , dysphagia ( food getting stuck on swallowing ) and haematemesis ( vomiting blood ). If there are any doubts about the diagnosis , or concerns , then it would be sensible to discuss with a GP or arrange a GP review . For those aged 55 and over , a combination of dyspepsia , nausea or vomiting with a raised platelet count or a low haemoglobin fits the criteria for an urgent endoscopy within two weeks and so it is definitely worth doing a full blood count in this group . 6 In practice , most GPs probably don ’ t have access to an endoscopy within two weeks and so will instead refer this group on the two-week wait pathway .
Ask also about lifestyle issues , such as smoking and alcohol , that may worsen symptoms , about any trigger foods or times ( symptoms worse at night , for example , or eating just before bed ), and about any family history of upper GI cancer . 6 Check the notes for prescribed medicines and ask about any bought over the counter . If you are seeing untriaged patients with GORD then you need to be aware of some differential diagnoses ( see box 1 , left ). Examine the patient , looking for signs of weight loss ( many people don ’ t weigh themselves , but are their clothes loose ?), anaemia , jaundice , dehydration or an upper abdominal mass .
Unexplained cause So , let ’ s say that we have a patient with dyspepsia , no obvious alarm symptoms , no iatrogenic cause that you can stop , and nothing to suggest an alternative diagnosis . What now ? You ’ ve given lifestyle advice about weight , smoking and alcohol ( where appropriate ) and also suggested that they eat smaller meals and eat their evening meal at least 3-4 hours before going to bed , and that they avoid trigger foods , but none of this has helped .
Does everyone with dyspepsia need an oesophagogastro-duodenoscopy ( endoscopy or OGD for short )? In short , no . Many people with dyspepsia can be managed in the community without the use of this invasive test ,
Box 2 Helicobacter pylori eradication regimens 11
• All regimens are for seven days except where otherwise stated .
• PPI regimens are all twice daily and could include lansoprazole , omeprazole , esomeprazole , pantoprazole or rabeprazole .
• Antibiotics are all given twice daily unless otherwise stated .
• The BNF should be consulted for dosage .
First line
• PPI plus amoxicillin and either clarithromycin or metronidazole 400mg .
• If penicillin allergic , then PPI plus clarithromycin and metronidazole .
• If penicillin allergic with recent exposure to clarithromycin , PPI plus metronidazole and levofloxacin .
Second line
• PPI plus amoxicillin and either clarithromycin or metronidazole ( whichever was not used as first line ).
• If the patient has had recent exposure to clarithromycin and metronidazole , then seven to
10 days of a PPI , amoxicillin and either levofloxacin or tetracycline hydrochloride .
• If the person is allergic to penicillin , then a PPI , metronidazole and levofloxacin .
• If they are allergic to penicillin and have been recently exposed to quinolone antibiotics , then give seven days of quadruple therapy with a PPI , tripotassium dicitratobismuthate four times a day , metronidazole and tetracycline hydrochloride four times a day .
ONLINE Scan the QR code to access the fully referenced module , test your knowledge and download your certificate as long as you have been careful in your history taking , examination and documentation .
Testing for H . pylori First-line therapy would be to prescribe a proton pump inhibitor ( PPI ) such as lansoprazole or omeprazole for a month , or to test for Helicobacter pylori infection , and the second-line strategy is to do the other one of these – i . e . test for H . pylori if a month of PPI doesn ’ t work , or try a month of PPI if the test is negative . In reality , most people probably do both of these at the same time . If the patient responds to a PPI and symptoms recur on stopping , then long-term acid suppression therapy may be needed – more below about the pros and cons of this . Acid can also be suppressed with H2 receptor antagonists , but this option is probably less used since ranitidine became unavailable globally . 7 Other drugs in this class , such as cimetidine and famotidine , could be used but unless the patient fits the licensed criteria , such as having a duodenal ulcer , their use will largely be off-licence in the UK .
H . pylori is a type of bacteria found in the stomach and is now known to be a cause of gastritis and gastric ulcers . The discovery of this link is an example of how far scientists will go to advance the sum of human knowledge . In 1984 , the Australian doctor Barry Marshall had been working for some years on the hypothesis that H . pylori caused gastritis . Without a functional animal model , he decided to take matters into his own hands . After undergoing an OGD that showed a normal gastric mucosa , he drunk a culture of H . pylori . Within days he developed nausea and vomiting , and on day eight a repeat OGD showed a positive culture for H . pylori and marked gastritis . 8 After being treated with antibiotics he made a full recovery . His remarkable actions led to funding to investigate whether antibiotics could cure duodenal ulcer and eventually to a drastic fall in the need for gastrectomy to treat ulcers . 9
H . pylori testing is only advised if the patient has uninvestigated symptoms that may be GORD or more general dyspepsia , rather than for proven GORD . Over the years we have used various different tests to look for the bacterium , and the test you choose will depend on what