MBBS SAQ · Gastroenterology
Gastro-oesophageal reflux disease — alarm features, investigation and stepwise management
A final-prof / NEET-PG SAQ on GORD with alarm features — the candidate must recognise dysphagia + weight loss + PPI non-response as mandating urgent OGD (not further empirical therapy), grade oesophagitis by the Los Angeles classification, identify Barrett/stricture/malignancy, and reproduce the stepwise management ladder with drug doses. Distinguishes GORD from achalasia and eosinophilic oesophagitis.
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Question
A 58-year-old man presents with a 4-month history of worsening retrosternal burning after meals and at night, new dysphagia to solids, early satiety and a 5 kg weight loss. He has been taking omeprazole 20 mg daily for 8 weeks without relief. He is a smoker, BMI 31. Outline your assessment, the investigations you would order, and your stepwise management. Justify each decision.
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Diagnosis: GORD complicated by alarm features — malignancy and peptic stricture must be excluded. The cardinal heartburn supports GORD, but dysphagia, weight loss and failure to respond to an 8-week PPI course are alarm features that preclude a further empirical approach.[1][5]
Assessment (ABCDE + focused history):
- Confirm symptom pattern, drug adherence and PPI timing (30 min pre-meal); review LES-lowering drugs.
- Screen for GI bleeding (anaemia), assess hydration and nutrition, examine for epigastric mass, lymphadenopathy, scleroderma.
- Recognise the alarm features: dysphagia, weight loss, PPI non-response, age over 55 — all present here.
- Urgent upper GI endoscopy (OGD) via the 2-week-wait cancer pathway — the single most important step; allows direct visualisation, biopsy and grading.
- At OGD, grade any oesophagitis by the Los Angeles classification (A under 5 mm; B over 5 mm; C bridging folds; D circumferential); inspect for salmon-pink Barrett mucosa (biopsy for intestinal metaplasia and dysplasia), peptic stricture, and mass lesions.
- Biopsy findings to consider: Barrett (goblet cells), eosinophilic oesophagitis (over 15 eosinophils per HPF, rings/furrows), malignancy.
- Bloods: FBC (anaemia), U&E (Mg if long-term PPI), LFT; coagulation if intervention planned.
- If OGD is normal but symptoms persist: ambulatory pH-impedance monitoring off PPI — apply the Lyon Consensus 2.0 (AET over 6 percent conclusive; under 4 percent excluded; 4 to 6 percent inconclusive).[2]
- High-resolution manometry before any surgery to exclude achalasia and assess peristaltic reserve.
Management — stepwise, with justification:[1]
- Lifestyle foundation (all patients): weight loss (BMI 31), stop smoking, elevate head of bed, avoid eating within 3 hours of bedtime, reduce dietary triggers.
- Optimise PPI: ensure adherence and correct timing; if erosive disease confirmed, omeprazole 20 to 40 mg od (or esomeprazole 40 mg) for 8 weeks before meals.
- Address specific OGD findings: peptic stricture → endoscopic dilatation + lifelong PPI (biopsy stricture to exclude malignancy); Barrett without dysplasia → surveillance (OGD at 1 year then every 2 to 3 years); low/high-grade dysplasia → RFA/EMR; malignancy → MDT oncology pathway.
- Refractory GORD after confirmed objective disease: double-dose PPI, add nocturnal H2RA (famotidine 20 mg), consider prokinetic/baclofen; anti-reflux surgery (Nissen fundoplication) only if objective reflux confirmed and manometry normal.
- Deprescribe to the lowest effective PPI long-term; counsel on long-term PPI risks (osteoporosis, hypomagnesaemia, B12 deficiency, enteric infection) and taper rather than stop abruptly.
Common errors
- Treating empirically despite alarm features — escalating PPI instead of ordering OGD in a patient with dysphagia and weight loss misses malignancy.
- Mislabelling achalasia as refractory GORD — dysphagia to solids AND liquids with undigested regurgitation needs manometry; PPIs and fundoplication without excluding achalasia are harmful.
- Operating without objective reflux confirmation — surgery for symptom-only GORD (no pH study) yields poor outcomes.
- Not counselling on long-term PPI risks or failing to deprescribe.
- Forgetting Barrett surveillance intervals after a metaplastic biopsy.
Examiner notes
- The exam rewards the alarm-feature recognition triggering OGD rather than further empirical therapy.
- Reproduce the Los Angeles classification and the Lyon Consensus 2.0 AET thresholds verbatim to score full marks.
- State the PPI agent, dose, route, timing and duration (omeprazole 20 mg od, 30 min pre-meal, 8 weeks for erosive disease).
- A strong candidate names three differential diagnoses for refractory 'GORD' (achalasia, eosinophilic oesophagitis, functional heartburn) and the long-term PPI adverse effects.[1][5]
References3ShowHide
- [1]Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol, 2022.PMID 34807007
- [2]Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut, 2018.PMID 29437910
- [5]National Institute for Health and Care Excellence (NICE). Gastro-oesophageal reflux disease and dyspepsia in over 16s (NG188). NICE guideline, 2023.Source