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GORD / Acid Reflux — Assessment & Management UK primary care pathway · RCGP SCA preparation · NICE NG12 & CKS GORD
Progress 0 / 9
The full reasoning pathway — screen ALARM features for urgent OGD, treat uncomplicated reflux with PPI + lifestyle, step down responders, endoscope the refractory patient for Barrett's/oesophagitis, and review long-term therapy.StartDecisionInvestigateActionReferStop / Admit
PresentationGastro-oesophageal reflux
Heartburn, acid regurgitation, worse lying/bending/post-meal; nocturnal cough, hoarseness (LPR). Assess ALARM features, NSAID/bisphosphonate use, smoking, alcohol, weight.
Step 1 · Safety — ALARM features (NICE NG12)Urgent OGD needed?
  • Dysphagia — any age
  • Aged ≥55 + weight loss with reflux / dyspepsia / upper-abdo pain
  • GI bleeding (haematemesis/melaena), iron-deficiency anaemia
  • Persistent vomiting, epigastric mass
YES — red flag
Stop · referUrgent OGD — 2WW
Suspected oesophago-gastric cancer pathway. Stop PPI 2 weeks before OGD where possible (can mask malignancy). GI bleed → admit.
NO — uncomplicated
Step 2 · AssessClinical diagnosis + H. pylori
Diagnose clinically; review NSAIDs/triggers; consider H. pylori test-and-treat if dyspepsia overlaps. No routine endoscopy for typical uncomplicated reflux.
Step 7 · treat & assess response
Step 7 · Action — PPI + lifestyle, then titrateTreat 4–8 weeks, then step to response
  • Full-dose PPI (omeprazole 20–40 mg OD, 30 min before food) for 4–8 weeks + lifestyle measures.
  • Responds → step down to lowest effective / on-demand dose; annual review; consider stopping if symptom-free.
  • Partial → increase to BD dosing or switch PPI; add alginate (Gaviscon Advance) at night.
  • Refractory → confirm adherence/timing, reconsider diagnosis (cardiac, functional, eosinophilic oesophagitis), and refer for endoscopy to grade oesophagitis and assess for Barrett's / hiatus hernia.
Step 3/6 · response branch & escalation
Step 6 · ReferEscalation thresholds
  • 2WW · NICE NG12 any ALARM feature → urgent OGD.
  • Gastroenterology refractory symptoms despite optimised PPI, confirmed Barrett's oesophagus (endoscopic surveillance), severe oesophagitis (Los Angeles C/D), or assessment for anti-reflux surgery (fundoplication) in those wanting to avoid lifelong PPI.
  • Primary care typical reflux responding to PPI/lifestyle → manage and review.
Step 8 · lifestyle & deprescribe
Step 8 · Lifestyle — first-line for everyoneReduce reflux, rationalise PPIs
Weight loss (the most effective measure) · smaller, earlier meals; avoid eating 3 h before bed · raise the head of the bed · reduce alcohol, caffeine, fatty/spicy foods, chocolate · stop smoking · review trigger drugs (CCBs, nitrates, NSAIDs). Annual review of long-term PPIs — step down to lowest effective dose.
Step 9 · review & safety-net
Step 9 · Review & safety-netWhen to come back
Same-day / admit if new difficulty swallowing, vomiting blood, black stools, or unintentional weight loss. Review PPI response at 4–8 weeks; step down responders; re-evaluate (and consider endoscopy) if symptoms recur off treatment or fail to settle. Safety-net: long-standing reflux carries Barrett's risk — escalate persistent symptoms.
⚠️ Long-standing reflux carries Barrett's risk: persistent or refractory symptoms warrant endoscopy to grade oesophagitis and enrol surveillance — and stop the PPI 2 weeks before OGD so it doesn't mask malignancy.
1
Safety

Red Flags — Exclude Upper GI Cancer & Complications First (NICE NG12)

Reflux is common, but the examiner is testing whether you can spot the malignancy and bleed hiding within it. Screen every patient against NG12 alarm features before treating empirically.

Dysphagia — ANY age Difficulty swallowing solids/liquids → 2WW upper GI direct-access OGD (NICE NG12). Never attribute new dysphagia to reflux.
Age ≥55 + weight loss Weight loss PLUS upper abdominal pain, reflux OR dyspepsia → 2WW / direct-access OGD (NICE NG12).
GI bleeding Haematemesis, melaena or coffee-ground vomiting → 999 / same-day OGD. 10% mortality for acute upper GI bleed.
Epigastric mass / Troisier’s sign Palpable epigastric mass or left supraclavicular node → 2WW upper GI (gastric cancer).
Iron-deficiency anaemia Unexplained IDA with reflux → 2WW + consider lower-GI workup. Occult GI blood loss until proven otherwise.
Persistent vomiting Unexplained persistent vomiting or early satiety → consider OGD and gastric outlet obstruction.
NICE NG12 mandates urgent direct-access OGD for dysphagia at any age, and for patients aged 55+ with weight loss plus upper abdominal pain, reflux or dyspepsia. Oesophageal adenocarcinoma incidence has risen sharply in the UK and reflux is its principal risk factor — verbalise these thresholds rather than reflexively prescribing a PPI.
2
Diagnose

History — Confirm Reflux & Identify Drivers

A confident clinical diagnosis of GORD can be made from a typical history without investigation, provided no alarm features.

Cardinal symptoms
Heartburn (retrosternal burning, worse lying flat / bending / after meals) and acid regurgitation. Relief with antacids supports the diagnosis.
Atypical / extra-oesophageal
Chronic cough, nocturnal cough, hoarseness, globus, dental erosions, non-cardiac chest pain, worsening asthma.
Exclude cardiac pain
Exertional retrosternal pain, radiation to jaw/arm, breathlessness, diaphoresis → assess as possible ACS first. Do not anchor on “reflux” in a cardiac-risk patient.
Lifestyle drivers
Obesity, late/large meals, alcohol, caffeine, smoking, trigger foods, tight clothing.
Medication review
NSAIDs, aspirin, bisphosphonates, CCBs, nitrates, theophylline, anticholinergics — relax the LOS or injure mucosa.
Pregnancy
Very common in 3rd trimester. Lifestyle, alginates, then omeprazole if needed.
NICE CKS GORD states a clinical diagnosis can be made on typical symptoms without further testing in the absence of alarm features. Distinguishing reflux from cardiac chest pain is a frequently-tested safety point.
3
Diagnose

Examination — Largely to Exclude Sinister Pathology

Examination is usually normal in uncomplicated GORD; its purpose is to exclude red-flag pathology and quantify cardiovascular risk.

BMI / weight
Central obesity is the dominant modifiable driver; weight loss is first-line therapy.
Abdomen
Epigastric tenderness is common and non-specific. A hard epigastric mass or hepatomegaly → 2WW.
Lymph nodes
Left supraclavicular node (Virchow / Troisier) → gastric cancer metastasis → 2WW upper GI.
Cardio-respiratory
Exclude cardiac cause of chest pain; auscultate if aspiration suspected.
Mouth / dentition
Dental erosions and water brash support chronic acid exposure.
The examination in GORD is predominantly a screen for complications and mimics — gastric malignancy, aspiration, and cardiac disease. A normal exam supports empirical therapy in a patient without alarm features.
4
Diagnose

Investigations — Only When They Change Management

Uncomplicated GORD needs NO investigation. Test the right patients for the right reasons.

H. pylori test If dyspepsia overlap
Urea breath test or stool antigen if ulcer-type symptoms. Stop PPI 2 weeks before (false negatives). Test-and-treat in uninvestigated dyspepsia.
OGD Alarm features
For NG12 alarm features or refractory symptoms after optimised PPI. Diagnoses oesophagitis grade, stricture, Barrett’s.
Barrett’s surveillance
If confirmed → endoscopic surveillance by segment length/dysplasia. Premalignant — counsel and follow up.
FBC
Iron-deficiency anaemia → investigate for occult GI blood loss.
24h pH / manometry Pre-surgery
Specialist test before anti-reflux surgery or when diagnosis uncertain after OGD.
Routine endoscopy for typical reflux without alarm features is low-yield — NICE restricts OGD to alarm features or treatment failure. Barrett’s oesophagus carries ~0.3%/year progression to adenocarcinoma and warrants structured surveillance.
5
Treat

Management Ladder — Lifestyle, Then Acid Suppression

Combine lifestyle modification with stepped acid suppression; review and step down to the lowest effective dose.

Step 1Lifestyle & review drugs Weight loss, smaller/earlier meals, reduce alcohol/caffeine, stop smoking, raise head of bed, avoid triggers. Stop/switch causative drugs where safe.
Step 2Alginate / antacid PRN Gaviscon Advance after meals and at bedtime for mild/intermittent symptoms and in pregnancy.
Step 3Full-dose PPI 4–8 weeks Omeprazole 20–40 mg OD or lansoprazole 30 mg OD, 30–60 min before breakfast. First-line for proven/clinical GORD.
Step 4Optimise / escalate Check adherence and timing; if partial response increase to BD. Consider switching PPI.
Step 5H2RA add-on / alternative Famotidine 20–40 mg nocte for nocturnal breakthrough or PPI intolerance.
Step 6Step down & PRN Once controlled, reduce to lowest effective dose or on-demand. Annual review of long-term PPI.
Long-term PPI Review annually
Risks: hypomagnesaemia, B12 deficiency, C. difficile, fracture, rebound hyperacidity on stopping. Lowest effective dose; attempt step-down.
NICE CKS recommends a full-dose PPI for 4–8 weeks as initial therapy, then step-down to the lowest dose that controls symptoms (including on-demand). PPIs must be taken 30–60 minutes before food — a commonly missed point that explains many “PPI failures”.
6
Refer

Referral — Who, When, How Urgently

Most GORD is managed entirely in primary care. Refer for alarm features, diagnostic uncertainty, or treatment failure.

2WW upper GI
Dysphagia any age; age 55+ with weight loss + upper abdominal pain/reflux/dyspepsia; epigastric mass; IDA with upper GI symptoms (NICE NG12).
Same-day / 999
Haematemesis, melaena, GI bleed or haemodynamic instability.
Routine gastroenterology
Refractory symptoms despite optimised PPI; suspected/confirmed Barrett’s; recurrent symptoms after stopping PPI in younger patients.
Upper GI surgery
Proven GORD considering fundoplication (volume regurgitation, PPI dependence/intolerance) after pH/manometry.
Manage in primary care
Typical reflux, no alarm features, responding to lifestyle + PPI.
The referral logic in GORD is essentially the NG12 cancer pathway plus a small group needing specialist diagnostics or surgery. Verbalising precise NG12 thresholds demonstrates safe, guideline-concordant practice.
7
Lifestyle

Lifestyle & Self-Management

Weight loss The single most effective intervention in overweight patients — reduces intra-abdominal pressure and symptoms.
Meal pattern Smaller meals, avoid eating within 3 hours of lying down, smaller evening meal.
Trigger avoidance Alcohol, caffeine, spicy/fatty/acidic foods, chocolate, fizzy drinks.
Sleep position Raise the head of the bed (blocks under bedposts); left-lateral may help nocturnal reflux.
Smoking cessation Smoking lowers LOS tone; offer cessation support.
Self-care & OTC Antacids/alginates for intermittent symptoms; safety-net for alarm features or OTC failure.
Lifestyle measures address the mechanics of reflux and reduce reliance on long-term acid suppression. Weight reduction and meal timing have the strongest evidence; bed-head elevation specifically benefits nocturnal symptoms.
8
Treat

Special Situations

Pregnancy
Lifestyle + alginates first; omeprazole has the most safety data if acid suppression needed. Usually resolves postpartum.
Non-cardiac chest pain
Only after cardiac cause excluded. A PPI trial can be diagnostic and therapeutic in proven reflux-related chest pain.
Laryngopharyngeal reflux
Hoarseness, throat clearing, globus — longer PPI trial (BD, 8–12 weeks); ENT if persistent (exclude head & neck pathology).
PPI deprescribing
Taper rather than stop abruptly to limit rebound acid hypersecretion; switch to on-demand or H2RA cover.
Functional heartburn
Typical symptoms with normal OGD and pH study — manage as functional; consider low-dose TCA, reduce unnecessary PPI.
These scenarios test nuance: omeprazole in pregnancy, PPI rebound on withdrawal, and the overlap between reflux, laryngopharyngeal symptoms and functional heartburn. Recognising functional heartburn prevents endless PPI escalation.
9
Safety

Follow-Up, Monitoring & Safety-Netting

4–8 weeks
Review PPI response. If controlled → step down to lowest effective dose / on-demand. If not → check adherence/timing, escalate or investigate.
Annual
Review long-term PPI — confirm ongoing need, lowest dose, check magnesium/B12 if prolonged.
Barrett’s
Ensure enrolled in endoscopic surveillance at the recommended interval.
Safety-net — 2WW
New dysphagia, weight loss, or persistent vomiting at any review → urgent OGD, do not simply increase PPI.
Safety-net — 999
Haematemesis or melaena → emergency admission.
A longstanding GORD label must never become a cognitive anchor: new dysphagia or weight loss in a known refluxer demands re-triage against NG12. Annual review of long-term PPIs is a quality marker.
Educational use only. Pathway based on: NICE NG12 Suspected Cancer (2015, updated 2023/2025), NICE CKS GORD, NICE CG184 (GORD & dyspepsia), BSG Barrett’s guidelines. Always adapt to individual patient context, co-morbidities and local formulary.