Primary care

10-minute consultation BMJ: first published as 10.1136/bmj.325.7370.945 on 26 October 2002. Downloaded from Gastro-oesophageal reflux disease Janusz Jankowski, Roger Jones, Brendan Delaney, John Dent

This is part of A 45 year old man complains of heartburn (retrosternal Useful reading burning) and regurgitation, usually after food but also at a series of night, for six months. Symptoms are particularly bad De Caestecker J. ABC of the upper gastrointestinal occasional after a heavy, fatty meal. Physical straining, bending, tract. Oesophagus: heartburn. BMJ 2001;323:736-9. articles on stooping, or lying flat also worsen the symptoms. common Jankowski J, Harrison RF, Perry I, Balkwill F, problems in primary care What issues you should cover Tselepis C. Barrett’s metaplasia. Lancet 2000; 356:2079-85. x Heartburn is common (7% of adults have daily and 35% monthly symptoms) and is chronic and relapsing Digestive Diseases Centre and but usually benign. Consider why the patient has con- Epithelial Office, sulted; many are worried about heart disease or cancer. achieve prompt and lasting symptom relief within four Departments of x In two thirds of patients, heartburn does not and weeks in most patients. If symptoms do not disappear Oncology, Leicester progress. Those with longstanding disease ( > 5 years), completely, patients can take a second dose of PPI Royal Infirmary, however, may develop more severe symptoms as a before the evening meal. All PPIs have similar efficacy, Leicester LE1 5WW result of secondary strictures or ulcers. although some achieve better results in more severe Janusz Jankowski professor x In patients not receiving treatment, severity of oesophagitis than others. heartburn does not predict the presence, absence, or Guy’s, King’s, and Laparoscopic antireflux surgery can achieve an St Thomas’s School severity of oesophagitis. More specific symptoms for efficacy similar to PPIs when done in specialist centres. of Medicine, King’s reflux are postural symptoms, a rising from lower to However, many patients still require long term PPIs, College, London upper sternum, and response to treatment with a pro- Roger Jones and surgery is associated with mortality (0.25%) not Wolfson professor of ton pump inhibitor (PPI). In patients taking acid seen with PPI therapy. general practice suppressants, relief of heartburn predicts healing of Other drugs—H2 receptor antagonists are only mod- University of oesophagitis, allowing doses to be adjusted in initial erately effective at standard doses, and higher and Birmingham, and long term treatment. more frequent doses offer little long term advantages. Birmingham x No strong evidence exists to justify mandatory Brendan Delaney Antacids and prokinetics are only appropriate if symp- reader in primary Helicobacter pylori eradication in patients taking PPIs toms occur occasionally. In the vast majority of patients care and general long term. Eradication is important, however, in those combination therapy is less effective than increasing practice http://www.bmj.com/ with proved peptic ulcer disease. the PPI dose. Royal Adelaide x Barrett’s oesophagus develops in about 5% of people Tests for more recalcitrant cases—When symptoms are Hospital, Adelaide, with endoscopy positive reflux disease (erosive reflux Australia not adequately relieved, even with a twice daily PPI John Dent disease); 1% of these annually develop oesophageal (about 10% of patients with reflux), consider whether professor of adenocarcinoma. This aggressive malignancy affects symptoms are truly related to reflux and if the patient 5-15 people per 100 000 population, and its incidence is is taking the treatment properly. Other more Correspondence to: increasing. Men over 45 with at least 10 years of bother- specialised diagnostic tests, such as labelled swallow J Jankowski [email protected] some heartburn are most at risk. If subsequent tests, and 24 hour pH monitoring, may then be on 29 September 2021 by guest. Protected copyright. endoscopy confirms Barrett’s oesophagus, long term The series is edited needed. by Ann McPherson surveillance may be indicated, and a gastroenterologist and Deborah Waller with an interest should guide management. Competing interests: The authors have received fees from The BMJ welcomes AstraZeneca and Janssen-Cilag for reimbursement, speaking, contributions from and consulting. JJ and JD have also received fees from general practitioners What you should do AstraZeneca for organising , research, and staff. to the series Patient’s lifestyle—The place of non-drug measures and antacids has not been firmly established. The BMJ 2002;325:945 exception is raising the head of the bed, although patients rarely do this long term. However, always give Indications for prompt gastroscopy appropriate, individualised advice about obesity, smok- • Alarm symptoms suggesting malignancy, stricture, or ing, alcohol, and avoidance of provocative foods. severe ulceration: dysphagia, jaundice, iron deficiency Screening for alarm features—Refer the patient for anaemia, unintentional weight loss, or abdominal mass endoscopy if indicated (box). • Age more than 45-55 years* with new onset A trial of acid suppressants for four weeks is appropriate dyspepsia or continuous epigastric pain for most patients with gastro-oesophageal reflux disease, • Non-specific or atypical symptoms not responding providing prompt symptoms relief and efficient diagno- to PPI therapy sis. Because 50-60% of patients have no endoscopically • Longstanding symptoms, especially in those over recognisable oesophagitis (non-erosive reflux disease), 45-55,* who may be at risk of complications such as endoscopy is an insensitive test for gastro-oesophageal stricture, severe oesophagitis, or Barrett’s oesophagus *Regional differences in gastro-oesophageal cancer exist in the reflux disease. . Use audit to determine the local threshold age Optimal dose and type of PPI—Standard dose PPI for referral therapy once daily is the treatment of choice and will

BMJ VOLUME 325 26 OCTOBER 2002 bmj.com 945