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GPs go forth

Initial presentation

Reflux occurs when the contents of the stomach flow back into the oesophagus. This can result in symptoms of heartburn and regurgitation. When patients first present with this condition in your practice, it is important to follow a stepwise approach to treatment. This involves starting patients on alginate or antacid therapy and stepping up to proton pump inhibitors (PPIs) if required. Explore the patient case below to find out more about managing patients presenting with reflux.

Watch now to hear patients' first-hand accounts of their reflux and heartburn experiences
  • About the patient

    Giovanni is 35 years old and has been experiencing heartburn and regurgitation intermittently for the last eight weeks. These symptoms occur approximately 3–4 times per week and cause him pain and discomfort. He reports sporadic use of over-the-counter alginates. He is a heavy smoker and drinks approximately 13 units on the weekend.

  • Treatment goals

    When treating Giovanni, you should ensure the treatments you prescribe alleviate his troublesome symptoms and help him maintain a good quality of life. If possible, you should aim to avoid reliance on long-term therapies, such as PPIs.

  • Challenges faced

    1. Identifying red flags

      Red flags must be addressed immediately (e.g. referral for further investigation). Older patients with a long history of reflux symptoms should be considered red-flag patients.

    2. Avoiding unnecessary endoscopy

      Not all reflux patients require referral for an endoscopy as it is an invasive procedure that causes discomfort to the patient and should be avoided if possible. Endoscopy should be reserved for patients with red flags, and those at higher risk of Barrett’s oesophagus (i.e. those with a long history of reflux).

    3. History taking

      Appropriate history taking is the foundation of effective diagnosis. Documenting the exact symptoms experienced is necessary in this process. For example, patients may misidentify chest pain as reflux symptoms, meaning you should ask them to describe their symptoms to avoid any potential inaccuracies.

  • Consultation advice

    You should follow the step-up approach when considering Giovanni’s treatment.

    • Patient education

      Educating Giovanni on his condition is important to ensuring effective self-management. You should aim to further his understanding of the treatments he is prescribed, and how to take them appropriately.

    • Managing self-care

      You should first ensure Giovanni is following effective strategies to manage his condition. Rather than waiting until the heartburn starts, taking regular over-the-counter alginates can help prevent troublesome symptoms. It is important that Giovanni knows how to take alginates appropriately, i.e. regularly after meals, before considering stepping up his therapy.

    • Regular alginate therapy

      If self-management is not effective, Giovanni should be prescribed regular alginate therapy. Giovanni should be reminded to follow the prescription instructions, i.e. take the alginates regularly after meals for eight weeks, in order for them to work effectively.

    • PPI therapy if required

      If Giovanni’s symptoms are not managed on alginates after the recommended eight-week treatment period, you can step up his treatment to PPI therapy. If this is required, a plan should be made for an eventual step-down.

    • Lifestyle changes

      As lifestyle can be a key contributor to Giovanni’s reflux, it is important to implement key lifestyle changes into his care plan. Addressing lifestyle problems, such as excessive smoking and drinking, can reduce his experience of reflux and prevent the need to step up PPI therapy.

  • Resources

This content hub is funded by RB. The view and opinions presented here represent those of the doctors and do not reflect those of RB.

Date of preparation: October 2018

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