Definition:
- Extremely common
Main features:
- Nausea
- Bloating and belching
- Heartburn
- Acid regurgitation, especially lying down at night
- Water brash
- Nocturnal cough with possible asthma like symptoms
- Diagnosis usually made on history
- investigation usually not needed unless red flag features present
Red flag features
- Anaemia
- Dysphagia
- Odynophagia (painful swallowing)
- Haematemesis or melaena
- Unexplained weight loss > 10%
- Vomiting
- Older age > 50 years
- Chronic NSAID use
- Severe symptoms
- Family history of upper GIT or colorectal cancer
- short history of symptoms
Investigations
- Gastroscopy (around 2/3 patients have normal gastroscopy)
Murtagh's diagnostic triad
Management plan:
- If mild intermittent symptom (no more than once per week), trial of lifestyle management first:
- weight reduction
- eating smaller meals
- drinking most fluid between meals rather than with them
- avoiding lying down after eating
- avoid eating or drinking 2 to 3 hours before bedtime or vigorous exercise
- elevating the bedhead
- losing weight
- Stopping smoking
- Decreasing alcohol consumption
- Pharmacological intervention
- MgOH + Aluminium hydroxider preparations 10 to 20 ml orally
- antacid plus alginate prepartions 10 to 20 ml orally
- A histamine h2 receptor antagonist e.g. ranitidine 150 mg once or twice daily
- PPI
- Fail to respond to PPI after 8 weeks warrants further investigation
- If moderate to severe symptoms (twice or more per week) --> start on PPI
- Maintenance therapy
- try stopping PPI (30% of people have prolonged remission of symptoms)
- step down to the lowest dose possible
- NPS has an educational module on how to stop PPIs.
- PPIs are fairly safe to use but the safety profile in long term use is uncertain. Some potential side effects associated with long term use include: fracture, increase enterc infection, vitamin b12 deficieny, iron and magnesium deficiency and pneumonia. (Please see reference 3)
References:
- John Murtagh's general practice 5th edition
- eTG
- http://www.nps.org.au/publications/health-professional/medicinewise-news/2015/proton-pump-inhibitors
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