QuestionSBA
QuestionChoice
Pain from pericarditis is worse when laying flat, with most patients noting significant relief from positional adjustment to sitting forwards. However, it would not only occur at night, nor would it explain the halitosis
33347
e
Pericarditis
QuestionChoice
This patient would be quite young to have developed coronary disease significant enough to cause an MI. In addition, the pain has been ongoing for two weeks and does not sound cardiac in nature (burning rather than crushing pain and no mention of it being related to exertion)
33346
d
Myocardial infarction (MI)
QuestionChoice
With a PE, chest pain is expected to be more pleuritic in nature, and not affected by position. Additionally, there is no mention of any risk factors for thrombus formation
33344
b
Pulmonary embolism (PE)
QuestionChoice
In PUD, there is often a more direct relationship of the pain to food – worse when hungry/relieved by food for duodenal ulcers, pain exacerbated by eating for gastric ulcers
33345
c
Peptic ulcer disease (PUD)
QuestionChoice
Patients with reflux may present with "chest pain" which is burning in nature ("heartburn"). Nocturnal symptoms or symptoms exacerbated by laying down or bending over are classical. Other associated symptoms may include halitosis, dysphagia, globus (the sensation of having a lump in the throat) and an unpleasant taste in the mouth
33343
a
Gastro-oesophageal reflux
Concept
Chapter
# Summary

Gastro-oesophageal reflux disease (GORD) is characterised by the reflux of gastric contents into the oesophagus due to a defective lower oesophageal sphincter. Key signs and symptoms include dyspepsia, sensation of acid regurgitation, and potentially more atypical symptoms such as epigastric pain and laryngitis. Alarm symptoms include weight loss and persistent vomiting. Key investigations include a trial of proton pump inhibitor therapy and oesophagogastroduodenoscopy (OGD) if certain symptoms are present. Management strategies include lifestyle interventions, proton pump inhibitor therapy, and in refractory cases, anti-reflux surgery.

# Definition

Gastro-oesophageal reflux disease (GORD) is a clinical diagnosis based on the presence of typical symptoms (dyspepsia, ""heartburn"" or ""acid reflux"") resulting from the reflux of gastric contents into the oesophagus caused by a defective lower oesophageal sphincter.

# Epidemiology

In the UK, about 10% of adults experience symptoms of GORD daily, with a higher prevalence observed in individuals over 50 years of age.

# Aetiology

GORD is caused by a defective lower oesophageal sphincter, which enables the reflux of gastric contents into the oesophagus.

Risk factors contributing to the development of GORD include obesity, alcohol use, smoking, and intake of specific foods (e.g. coffee, citrus foods, spicy foods, fat).


# Signs and symptoms

Typical symptoms:

- Dyspepsia (""heartburn"")
- Sensation of acid regurgitation 

Atypical symptoms:

- Epigastric or chest pain
- Nausea
- Bloating
- Belching
- Globus
- Laryngitis
- Tooth erosion

Alarm symptoms:

- Weight loss
- Anaemia
- Dysphagia
- Haematemesis
- Melaena
- Persistent vomiting

# Differential Diagnosis

Conditions that may present similarly and should be considered in the differential diagnosis include:

- Gastric ulcers: These may present with epigastric pain, nausea, vomiting, and weight loss.
- Oesophageal cancer: This may present with dysphagia, weight loss, and potentially haematemesis.
- Functional dyspepsia: This condition may present with similar gastrointestinal symptoms without a clear organic cause.
- Hiatus hernia: Often coexists with GORD but can cause pain without significant reflux.


# Investigations

-  Urea (13C) breath test, Stool Helicobacter Antigen Test (SAT), or laboratory-based serology  **if** symptoms suggestive of H.pylori infection.
- Oesophagogastroduodenoscopy (OGD) if alarm features or atypical, persistent or relapsing symptoms are present.
- Oesophageal manometry

**Referral criteria for urgent (within 2 weeks) OGD to investigate for oesophageal and gastric cancer:**

- Aged 55 years and over with weight loss + dyspepsia/reflux

Referral criteria for non-urgent OGD:

Aged 55 years and over plus

- Treatment-resistant dyspepsia
 
OR

- Raised platelet count + dyspepsia/reflux
- Nausea/vomiting + dyspepsia/reflux

# Management

- Lifestyle interventions - weight loss, dietary changes, elevation of the head of the bed at night, avoidance of late-night eating.
- Proton pump inhibitor therapy. For patients <40 years old who present with typical symptoms and no red flags, commence treatment with a standard-dose PPI for 4 weeks in combination with lifestyle changes.
	- If the patient meets criteria for urgent OGD, they should only be commenced on PPI therapy after this has been done
- Antacids for symptomatic relief.
- Anti-reflux surgery for refractory cases.
- Treatment for H.pylori infection if confirmed (PPI + antibiotics), with retesting using the urea breath test
	-  It should not be performed within 2 weeks of treatment with a proton pump inhibitor or within 4 weeks of antibacterial treatment, as this can lead to false negatives.

# Complications

Potential complications of GORD include:

- Oesophageal ulcer
- Oesophageal stricture
- Barrett's oesophagus
- Adenocarcinoma of the oesophagus

# NICE Guidelines 

- [NICE: Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management](https://www.nice.org.uk/guidance/cg184)

# References

- [BMJ Best Practice: Gastro-oesophageal reflux disease](https://bestpractice.bmj.com/topics/en-gb/82)
- [European Association of Endoscopic Surgery: Recommendations for the management of gastroesophageal reflux disease](https://link.springer.com/article/10.1007/s00464-014-3431-z)
2046
2638
Gastro-oesophageal reflux disease
Topic
23
Gastroenterology
6669
A 30-year-old man presents to his GP complaining of 2 weeks of burning chest pain which he experiences only when laying down in bed at night. His partner has also told him he has notable halitosis in recent months, which he finds embarrassing.

What is the most likely diagnosis?
a