Peptic ulcer surgery over 20 years previously.Family history of upper GI cancer in more than two first-degree relatives.Dyspepsia combined with at least one of the following known 'risk factors':.Dyspepsia in a patient aged 55 years or more with at least one of the following 'high-risk' features:.Dyspepsia at any age combined with one or more of the following 'alarm' symptoms:.Dysphagia - food sticking on swallowing, at any age.NICE guidelines for urgent referral for suspected upper GI cancer The National Institute for Health and Care Excellence (NICE) in the UK has published guidelines on the management of dyspepsia (including reflux symptoms) which impact on clinical practice . Infection (especially in the immunocompromised): cytomegalovirus, herpes, candidiasis.Oesophagitis from swallowed corrosives or drugs like NSAIDs.Grade D: mucosal breaks which involve ≥75% of the mucosal circumference.Grade C: mucosal breaks that extend between the tops of two or more mucosal folds but which involve Grade B: one or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds.Grade A: one or more mucosal breaks no longer than 5 mm, none of which extends between the tops of the mucosal folds.The more recent and more objective Los Angeles grades A to D classification is also used : Columnar metaplasia in the form of circular or non-circular (islands or tongues) extensions. Grade 4: ulcer, stenosis or oesophageal shortening.Grade 3: multiple circumferential erosions.Grade 2: multiple erosions affecting multiple folds.Erosions may be exudative or erythematous. Grade 1: single or multiple erosions on a single fold.The Savary-Miller grading system is commonly used : In 6-10% of patients with chronic cough, GORD is the underlying cause. Episodic or chronic aspiration can cause pneumonia, lung abscess and interstitial pulmonary fibrosis. Respiratory symptoms include chronic hoarseness (the Cherry-Donner syndrome), chronic cough, and asthmatic symptoms like wheezing and shortness of breath.Usually there is no relationship to exercise and this helps to differentiate most cases of reflux-induced chest pain from true angina. Non-cardiac chest pain caused by GORD has been found in up to 50% of patients with chest pain and normal coronary angiography.
These include chest pain, epigastric pain and bloating. Odynophagia (pain on swallowing) may be due to severe oesophagitis or stricture.Water brash - this is excessive salivation.Retrosternal discomfort, acid brash - regurgitation of acid or bile.Heartburn is a burning feeling, rising from the stomach or lower chest up towards the neck, that is related to meals, lying down, stooping and straining.NB: there is no relationship between Helicobacter pylori infection and GORD. Most of these predisposing factors increase intra-abdominal pressure and a fatty meal delays gastric emptying but the listed drugs and smoking relax the tone of the cardiac sphincter. Drugs, including tricyclic antidepressants, anticholinergics, nitrates and calcium-channel blockers.Inadequate cardiac sphincter for anatomical reasons or factors that reduce tone, and also poor oesophageal peristalsis.Factors that predispose to reflux include:
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