Table 28

Investigation and management of reflux

InvestigationsPotential resultsClinical management plan
Actions from history, medication and dietary assessment
History findingsPrevious upper GI surgery

  1. Refer to dietitian

    • Avoid eating late at night.

    • Raise head of the bed.

    • Reduce smoking, alcohol, caffeine, fat.

    • Reduce weight if high BMI.

    • Avoid large portions.

  2. Assess for SIBO.

  3. Trial of PPI (unless after total gastrectomy)

  4. Trial of agents to reduce biliary reflux. (p. 25).

  5. Trial of prokinetics. (p. 26).

Stress related

  1. Consider stress management techniques.

  2. Consider referral for psychological support.

First line
OGDInflammation/ulcerationSee management of acid or bile related inflammation (p. 25).
Lifestyle changes: reduce smoking, alcohol, chocolate, caffeine, fatty food, carbonated drinks, citrus.
Assess weight and BMI.
Malignancy/tumour recurrenceDiscuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
Pyloric stenosis (after upper GI surgery)Consider dilatation (p. 25) with careful biopsy only after agreement from the appropriate MDT.
Barium swallowOesophageal strictureSee the guidance in tables 14 and 16.
Delayed emptying

  1. Assess for SIBO (p. 21).

  2. Prokinetics (p. 26).

  3. Consider formal gastric emptying studies.

  4. Consider dilatation (p. 25) with careful biopsy only after agreement from the appropriate MDT.

Oesophageal spasm

  1. Start PPI or H2 antagonist.

  2. Calcium antagonist.

  3. Low dose antidepressant, eg, citalopram.

  4. Confirm with oesophageal manometry, pH/impedance studies.

ECG/exercise testCardiac relatedThis is an emergency. Refer to cardiology.
Second line
Oesophageal manometry/pH/impedance studiesSpasmCalcium antagonist.
Low dose antidepressant, eg, citalopram.
Refer to gastroenterology.
Scleroderma

  1. Start PPI or H2 antagonist.

  2. Refer to rheumatology.

Third line
If normal investigations/no response to interventionReassure.

  • BMI, body mass index; GI, gastrointestinal; MDT, multidisciplinary team; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PPI, proton pump inhibitor; SIBO, small intestinal bacterial overgrowth.