GORD counselling and red-flag assessment

PLAB 2 & PRES 3 · gastro · medium · 8 minutes

Candidate brief

You are a doctor in a GP practice. Mr Daniel Byrne, 48, has experienced frequent heartburn and an acidic taste in his mouth for 4 months. Assess his symptoms, exclude important alternative diagnoses and red flags, explain the likely cause and agree an appropriate management plan. No physical examination is required, but verbalise any examination or investigations you would consider.

What examiners look for

Typical GORD symptoms include burning behind the breastbone and acidic regurgitation, often worse after meals, lying down or bending over. Do not automatically attribute chest discomfort to reflux. Ask about exertional pressure, radiation, breathlessness, sweating, nausea, cardiovascular risks and other possible emergency causes. Alarm features include dysphagia, painful swallowing, food sticking, unexplained weight loss, persistent vomiting, gastrointestinal bleeding, anaemia and an upper abdominal mass. Routine endoscopy is not required for uncomplicated reflux without alarm features. Consider referral when red flags, treatment failure, diagnostic uncertainty, complications or important Barrett’s oesophagus risk factors are present. Offer a full-dose proton pump inhibitor for 4 or 8 weeks. If symptoms recur, aim for the lowest effective dose or suitable on-demand treatment. Personalise lifestyle advice. Avoid blanket food restrictions. Focus on the patient’s triggers, weight reduction where appropriate, smaller meals, avoiding food for 3–4 hours before bed, smoking cessation and alcohol moderation. For nocturnal symptoms, raise the head of the bed by approximately 10–20 cm. Extra pillows alone may worsen abdominal pressure. Review long-term PPI treatment regularly and safety-net clearly for new alarm or cardiac symptoms.

Guideline references

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