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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- GORD = reflux of gastric acid into oesophagus causing heartburn and regurgitation; diagnosed clinically in most cases
- First-line treatment: full-dose PPI (e.g. omeprazole 20 mg OD) for 4–8 weeks, then step-down to lowest effective dose
- Test-and-treat for H. pylori in uninvestigated dyspepsia (urea breath test or stool antigen test)
- Urgent 2-week-wait endoscopy for dysphagia, ≥55 years with weight loss + upper GI symptoms, or treatment-resistant symptoms
- Barrett's oesophagus: intestinal metaplasia of distal oesophagus — risk factor for oesophageal adenocarcinoma; consider surveillance endoscopy
Overview
Gastro-oesophageal reflux disease is caused by abnormal reflux of gastric contents into the oesophagus. It encompasses endoscopically confirmed oesophagitis and endoscopy-negative reflux disease (NERD). The underlying mechanism involves transient lower oesophageal sphincter relaxation, impaired oesophageal clearance, and/or increased intra-abdominal pressure. Risk factors include obesity, hiatus hernia, pregnancy, smoking, and certain medications (calcium channel blockers, nitrates, NSAIDs). Complications include oesophagitis, stricture, Barrett's oesophagus, and oesophageal adenocarcinoma.
Epidemiology
GORD is extremely common, affecting approximately 10–20% of the Western population. Heartburn occurs at least weekly in 10–15% of UK adults. It is more common in males, particularly for erosive oesophagitis and Barrett's oesophagus. Prevalence increases with age and BMI. Barrett's oesophagus is found in approximately 1–2% of the general population and up to 10–15% of those undergoing endoscopy for GORD symptoms.
Clinical Features
Symptoms
Heartburn (retrosternal burning, worse after meals and on lying flat)
Acid regurgitation (sour/bitter taste in mouth)
Dysphagia (progressive difficulty swallowing)
Odynophagia (painful swallowing)
Waterbrash (sudden excess saliva production)
Chronic cough, hoarseness, or dental erosion (extra-oesophageal manifestations)
Unexplained weight loss
Epigastric pain
Signs
Usually no abnormal findings on examination
Epigastric tenderness (mild, non-specific)
Dental enamel erosion (chronic acid exposure)
Iron deficiency anaemia (from erosive oesophagitis or Barrett's)
Investigations
First-line
Clinical diagnosisTypical heartburn and regurgitation can be treated empirically — endoscopy not routinely required for initial diagnosis
H. pylori test (urea breath test or stool antigen)Test-and-treat strategy for uninvestigated dyspepsia. Stop PPI ≥2 weeks before breath test
Second-line
Upper GI endoscopy (OGD)If red flags present (dysphagia, weight loss, ≥55 with new symptoms, GI bleeding, persistent vomiting), treatment failure, or suspected Barrett's
Biopsy of Barrett's segmentIf columnar-lined oesophagus seen at OGD — to assess for intestinal metaplasia and dysplasia (Prague classification)
Specialist
24-hour oesophageal pH/impedance monitoringGold standard for confirming pathological reflux — used when diagnosis uncertain or pre-operative assessment for fundoplication
Oesophageal manometryPre-operative assessment before anti-reflux surgery to exclude motility disorder
1
Lifestyle measures
- Weight loss if overweight/obese
- Avoid trigger foods, smoking, and alcohol
- Elevate head of bed, avoid eating within 3 hours of bedtime
- Review medications that may worsen reflux (NSAIDs, CCBs, nitrates, bisphosphonates)
2
Pharmacological — first-line
- Full-dose PPI for 4–8 weeks (e.g. omeprazole 20 mg OD, lansoprazole 30 mg OD)
- If symptoms recur, step-down to lowest effective PPI dose or use on-demand
- H2RA (e.g. ranitidine alternative — famotidine 20 mg BD) if PPI inadequate response
3
H. pylori eradication (if positive)
- First-line triple therapy: PPI + amoxicillin 1 g BD + clarithromycin 500 mg BD or metronidazole 400 mg BD for 7 days
- Second-line: PPI + amoxicillin + metronidazole (or levofloxacin-based if penicillin-allergic) for 7 days
- Confirm eradication with urea breath test or stool antigen ≥4 weeks after completion
4
Referral and surgery
- Refer for endoscopy if: dysphagia, persistent vomiting, GI bleeding, unexplained weight loss, or ≥55 with new-onset symptoms
- Laparoscopic fundoplication (Nissen) for confirmed GORD refractory to medical therapy — requires pre-op pH study and manometry
- Barrett's oesophagus: consider surveillance endoscopy depending on risk factors; refer high-grade dysplasia for ablation or surgery
Complications
- Oesophagitis: Erosive inflammation of oesophageal mucosa (Los Angeles classification A–D)
- Oesophageal stricture: Fibrous narrowing from chronic inflammation — presents with progressive dysphagia; treated with endoscopic dilatation
- Barrett's oesophagus: Intestinal metaplasia replacing squamous epithelium — pre-malignant condition; ~0.5% annual risk of progression to oesophageal adenocarcinoma
- Oesophageal adenocarcinoma: ~30-fold increased risk in Barrett's with high-grade dysplasia
- Aspiration pneumonia: From chronic nocturnal reflux (especially in elderly)
UKMLA Exam Tips
- 1Dysphagia = always investigate with OGD — red flag symptom regardless of age
- 2Test-and-treat H. pylori in uninvestigated dyspepsia BEFORE endoscopy (unless red flags present)
- 3Stop PPI ≥2 weeks before urea breath test or stool antigen test — PPIs cause false negatives
- 4Barrett's oesophagus = columnar (intestinal) metaplasia, NOT dysplasia — dysplasia is a further step towards malignancy
- 5Alarm features for urgent OGD referral: Dysphagia, Anaemia (iron deficiency), Loss of weight, Anorexia, Recent onset progressive symptoms, Melaena/haematemesis, Swallowing difficulty (mnemonic: ALARMS)
- 6Long-term PPI use: associated with hypomagnesaemia, C. difficile risk, and osteoporosis — use lowest effective dose
practicetest your knowledge on gordApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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