GORD Course

1. Gastro-Oesophageal Reflux Disease (GORD)
In Primary Care
Juan Mendive
ESPCG Review Panel:
Pali Hungin
Niek de Wit
Roger Jones
Richard Stevens
The European Society for
Primary Care Gastroenterology (ESPCG)
This material was developed by ESPCG,
in receipt of an unrestricted educational
grant from RB.

2. MODULE 1
• Introduction
• Aim and objectives of the course
• Methodology of the course
• Pre-test for initial assessment
• Areas of GORD on the course
• Clinical case 1
• Definition of GORD
• Reflux considerations
• Symptoms of GORD
• Classification of GORD

3. MODULE 1
INTRODUCTION
• Gastro-Oesophageal reflux disease (GORD) is a
common problem in the general population.
• It causes high demands in primary care consultations, which can
be up to 5% of all GP consultations in Western countries *
• If symptoms are severe, it may produce a significant impact on
quality of life
* Liker H, Hungin P and Wiklund I. Managing gastroesophageal reflux disease in primary care:
the patient perspective. J Am Board Fam Pract 2005;18:393-400.

4. MODULE 1
INTRODUCTION (2)
• Knowledge, attitudes and skills of GPs do not always meet
population needs
• To improve these aspects, as far as GORD is concerned, the
European Society for Primary Care Gastroenterology (ESPCG) has
decided to promote a number of activities to improve GPs’
knowledge of the management of this common condition.
• This GORD online course is intended to be a key element of that.

5. MODULE 1
AIM
The acid pocket is a putative mechanism, and this course aims
to help GPs to improve their knowledge, skills and attitudes
in the clinical management of patients suffering from GORD,
based on the most up-to-date evidence.

6. MODULE 1
OBJECTIVES OF THE COURSE
• Review and update the management criteria of GORD in primary
care
• Incorporate the new concepts of the pathophysiology of GORD.
• Present in a practical way the different available therapeutic
options for GORD.
• Review the different profiles of GORD patients most frequently
seen in primary care and examine the management options for
these profiles.

7. MODULE 1
METHODOLOGY OF THIS COURSE
Learning in this session will be established through the
presentation of common scenarios of patients suffering from
GORD in the context of primary care.
We believe that the learning process is more effective if it is
based on real cases seen and managed in primary care
practice.
A comprehensive approach to GORD will include different
aspects of this disease in order to achieve a complete
understanding of this condition.

8. MODULE 1
PRE-TEST FOR INITIAL ASSESSMENT
1: Which of the following is true with respect to physiological
reflux?
A: It is pre prandial, of short duration and symptomatic
B: It is post prandial, short and asymptomatic
C: It is pre prandial, of short duration and asymptomatic
D: It is post prandial, long lasting and symptomatic

9. MODULE 1
PRE-TEST FOR INITIAL ASSESSMENT
1: Which of the following is true with respect to physiological
reflux?
A: It is pre prandial, of short duration and symptomatic
B: It is post prandial, short and asymptomatic
C: It is pre prandial, of short duration and asymptomatic
D: It is post prandial, long lasting and symptomatic
Correct = B. Physiological post prandial reflux is of short
duration and is asymptomatic

10. MODULE 1
2. According to the Montreal Definition, which of the
following is not a syndrome with oesophageal injury?
A. Reflux esophagitis
B. Barrett’s esophagus
C. Reflux Chest Pain
D. Stenosis due to reflux

11. MODULE 1
2. According to the Montreal Definition, which of the
following is not a syndrome with oesophageal injury?
A. Reflux esophagitis
B. Barrett’s esophagus
C. Reflux Chest Pain
D. Stenosis due to reflux
Correct answer = C. According to the Montreal Definition,
syndromes with oesophageal injury are reflux esophagitis,
reflux stricture, Barrett's esophagus and oesophageal
adenocarcinoma.

12. MODULE 1
3. Which of the following is not considered an important risk
factor for adenocarcinoma of the esophagus?
A. obesity
B. chronic GORD
C. duodenal ulcer
D. Barrett’s esophagus

13. MODULE 1
3. Which of the following is not considered an important risk
factor for adenocarcinoma of the esophagus?
A. obesity
B. chronic GORD
C. duodenal ulcer
D. Barrett’s esophagus
Correct Answer = C. Duodenal ulcer is not considered a risk
factor for oesophageal adenocarcinoma

14. MODULE 1
4. Which of the following, do you consider an alarm symptom
in a patient with GORD?
A. heartburn
B. regurgitation
C. dysphagia
D. dyspepsia

15. MODULE 1
4. Which of the following, do you consider an alarm symptom
in a patient with GORD?
A. heartburn
B. regurgitation
C. dysphagia
D. dyspepsia
Correct answer = C. In a patient with GORD dysphagia is not
uncommon but is considered a warning sign that requires
investigation when it is persistent or progressive.

16. MODULE 1
5. The acid pocket
A. Is a biochemical alteration
B. Is a normal situation
C. Is an unproven concept

17. MODULE 1
5. The acid pocket
A. Is a biochemical alteration
B. Is a normal situation
C. Is an unproven concept
Correct answer = C. The acid pocket is an area in the gastric
fundus that, under physiological conditions, always remains at
an acidic pH.

18. MODULE 1
AREAS OF GORD ON THE COURSE
• Definition, symptoms and diagnosis including new
pathophysiological concepts
• Epidemiology , morbidity and quality of life
• Treatment options according to specific profiles
• Follow-up in primary care
• Complications of GORD and its management
All of these will be introduced through practical clinical cases
(patients’ scenarios in primary care)

19. MODULE 1
CLINICAL CASE 1
• Peter is a male, 47 years old.
• He has smoked 3 packs of cigarettes a
day for many years.
• Has no relevant medical history.
• He complains of continuous retro-
sternal burning for the last 2 weeks.
Sometimes he has the feeling that food
is coming up into his throat after eating.
No problems sleeping . No chest pain.
• He has tried antacids provided over the
counter (OTC) from the pharmacy but
this does not achieve complete relief.

20. MODULE 1
CLINICAL CASE 1 (2).
ASPECTS TO THINK ABOUT
• Does this patient have GORD ?
• What are the pointers for GORD here?
Can we make the diagnosis of GORD in this patient
with no further investigations?
• To manage this patient in the best way we need to
clarify first the definition of GORD.

21. MODULE 1
DEFINITION OF GORD
• GORD is defined by consensus. The most commonly used is the
Montreal definition :
‘A condition that occurs when there is reflux of stomach contents into the
oesophagus and sometimes upper to the oral cavity (including the larynx)
or even lungs. It can produce troublesome symptoms and/or
complications.’
• GORD is a condition which develops when the reflux of stomach contents
causes troublesome symptoms and/or complications
• This GORD definition was developed in 2006 by an international expert
group who met in Montreal in order to propose a definition for this
condition. It was followed by a Delphi process, based on systematic
reviews of the literature.
• The Montreal definition has been adopted by the main GI associations
such as United European Gastroenterology (UEG) and the American
College of Gastroenterology (ACG) .

22. MODULE 1
REFLUX CONSIDERATIONS
• Physiological reflux: Some degree of reflux is
physiological and occurs primarily in the post
prandial period. It is short, asymptomatic and rarely
occurs during sleep.
• The Montreal expert group described heartburn as
troublesome when it produces mild symptoms at
least 2 days a week or moderate-severe symptoms at
least once a week.

23. MODULE 1
GORD SYMPTOMATOLOGY
• GORD can manifest in many different ways. The GORD
syndrome is typically defined by the presence of:
• Heartburn. This is described as a burning sensation in the
retro-sternal area and is usually more common after eating.
GORD is the most common cause of heartburn.
• Regurgitation. This is the feeling of gastric contents
returning up to the hypo pharynx and mouth, without
nausea.

24. MODULE 1
OTHER GORD SYMPTOMS
• Dysphagia. Not very frequent. It is considered a warning sign (‘red
flag’) that requires further investigation. The test of choice in these
cases is usually upper GI endoscopy.
• Chest pain. It is important to be sure that there is no coronary heart
disease before attributing chest pain to GORD, which can be very
similar to angina and patients describe it as oppressive or burning,
located in the retrosternal region and may radiate to back, neck,
jaw or arms. The duration is variable from minutes to hours.
Typically it appears after ingestion or after getting up from sleep. It
may be a single symptom without any heartburn or regurgitation.
GORD causes chest pain more frequently than oesophageal motor
disorders.
• Hyper salivation. Not very frequent . It is thought to occur in
response to reflux.

25. MODULE 1
ATYPICAL GORD SYMPTOMS
• Odynophagia (painful swallowing). Not seen very often . It it appears, esophagitis
should be suspected.
• Globus sensation – a feeling of a lump or something lodged in the throat. Not very
frequent but very disturbing . It is currently under discussion if it is a symptom of
GORD or if it is secondary to a increased tone of the upper oesophageal sphincter.
• Nausea. It is rare. Other causes must be ruled out before attributing it to GORD.
• Sleep disturbances. A population study showed that 25% of patients had
symptoms of reflux during sleeping and that reflux had a negative impact on their
quality of life.
• Epigastric pain. Several clinical trials in patients with non erosive GORD
(endoscopic) showed that 69% of patients had dyspepsia associated with typical
symptoms (heartburn and regurgitation) and this disappeared after acid
suppression. The role of reflux as a cause of non-ulcer dyspepsia is under
discussion.

26. MODULE 1
RESPIRATORY SYMPTOMS IN GORD
• There is a relationship between GORD and chronic
cough, asthma and chronic laryngitis that may not be
associated with typical symptoms (heartburn and
regurgitation).
• However, it is considered that these symptoms are
often multifactorial and GORD acts as co-factor.
• Response to anti-secretory treatment is usually poor,
with the need for increasing treatment dose and
duration in most cases.

27. MODULE 1
CLASSIFICATION OF GORD
Based on symptoms we can make a first classification according to
the Montreal Definition* in:
• GORD with oesophageal symptoms.
• GORD with extra-oesophageal symptoms.
GORD can also be classified according to the endoscopic findings:
• Non-erosive reflux disease (NERD). Symptoms without endoscopic
evidence of injury.
• Erosive reflux disease (ERD). Symptoms with evidence of injuries at
endoscopy.
* Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal
reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900-1920

28. MODULE 1
GORD CLASSIFICATION:
THE MONTREAL DEFINITION

29. MODULE 1
MODULE 1 – TAKE-HOME MESSAGES
• GORD is a very common condition
• Typical symptoms are heartburn and regurgitation
• Extra-gastrointestinal symptoms such as chronic cough
are frequent in GORD
• The Montreal Definition describes both types of
symptoms, gastrointestinal and extra-gastrointestinal
• GORD can also be classified as erosive and non-erosive,
according to the endoscopic findings.