10-minute consultation: Gastro-oesophageal reflux disease.

What issues you should cover x Heartburn is common (7% of adults have daily and 35% monthly symptoms) and is chronic and relapsing but usually benign. Consider why the patient has consulted; many are worried about heart disease or cancer. x In two thirds of patients, heartburn does not progress. Those with longstanding disease ( > 5 years), however, may develop more severe symptoms as a result of secondary strictures or ulcers. x In patients not receiving treatment, severity of heartburn does not predict the presence, absence, or severity of oesophagitis. More specific symptoms for reflux are postural symptoms, a rising from lower to upper sternum, and response to treatment with a proton pump inhibitor (PPI). In patients taking acid suppressants, relief of heartburn predicts healing of oesophagitis, allowing doses to be adjusted in initial and long term treatment. x No strong evidence exists to justify mandatory Helicobacter pylori eradication in patients taking PPIs long term. Eradication is important, however, in those with proved peptic ulcer disease. x Barrett’s oesophagus develops in about 5% of people with endoscopy positive reflux disease (erosive reflux disease); 1% of these annually develop oesophageal adenocarcinoma. This aggressive malignancy affects 5-15 people per 100 000 population, and its incidence is increasing. Men over 45 with at least 10 years of bothersome heartburn are most at risk. If subsequent endoscopy confirms Barrett’s oesophagus, long term surveillance may be indicated, and a gastroenterologist with an interest should guide management.