EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess Daniel’s symptoms?

• Prompt: What key features help differentiate GORD from other upper GI conditions?
• Prompt: What red flag symptoms require urgent investigation?

Q2. What investigations, if any, would you order to assess Daniel’s condition?

• Prompt: When is an upper endoscopy indicated?
• Prompt: What tests can support a diagnosis of GORD?

Q3. Outline an initial management plan, including lifestyle and pharmacological interventions.

• Prompt: What lifestyle modifications would you recommend?
• Prompt: How would you use proton pump inhibitors (PPIs) safely?

Q4. How would you educate Daniel on his diagnosis and long-term management?

• Prompt: How would you reassure him about his cancer concerns?
• Prompt: What is the role of ongoing follow-up in GORD?

Q5. Daniel returns in three months with persistent symptoms despite lifestyle changes and PPI therapy. What would you do next?

• Prompt: What are the next steps in his management?
• Prompt: When would you refer him to a gastroenterologist?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess Daniel’s symptoms?

A thorough history is essential to assess Daniel’s symptoms, differentiate gastro-oesophageal reflux disease (GORD) from other conditions, and identify red flags.

1. Symptom Characteristics:

• Onset, duration, and frequency of symptoms.
• Triggers: Fatty meals, alcohol, caffeine, lying down.
• Associated symptoms: Regurgitation, dysphagia, nausea.

2. Red Flag Symptoms (Possible Oesophageal Cancer or Peptic Ulcer Disease):

• Unintentional weight loss.
• Persistent vomiting or haematemesis.
• Dysphagia or odynophagia.
• Family history of oesophageal or gastric cancer.

3. Lifestyle and Risk Factors:

• Diet: Spicy/fatty foods, late-night eating.
• Alcohol and smoking history.
• Physical activity and weight trends.

4. Medication Use:

• Overuse of NSAIDs or corticosteroids (risk of ulcers).
• Previous trial of acid suppression therapy.

5. Psychosocial Factors:

• Stress, anxiety, or work-related pressures.
• Impact on sleep and quality of life.

A structured history ensures accurate diagnosis and appropriate management.

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Q2: What investigations, if any, would you order to assess Daniel’s condition?

Investigations should be guided by symptoms and red flag features.

1. When to Consider Investigations:

• Typical GORD symptoms (no red flags): Empirical treatment trial (PPI).
• Red flag symptoms: Require urgent gastroscopy.
• Atypical symptoms (chronic cough, laryngitis, chest pain): May need further assessment.

2. Diagnostic Tests:

• Gastroscopy: If red flags, poor response to treatment, or long-standing symptoms (>5 years).
• 24-hour pH monitoring: If diagnosis is uncertain.
• H. pylori testing (faecal antigen, breath test): If ulcer disease suspected.

Appropriate investigations confirm diagnosis and guide treatment.

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Q3: Outline an initial management plan, including lifestyle and pharmacological interventions.

Management should be individualised and evidence-based.

1. Lifestyle Modifications (First-Line):

• Weight loss if overweight (BMI 31).
• Dietary changes: Avoid fatty/spicy foods, alcohol, caffeine.
• Meal timing: Eat 2-3 hours before bed, smaller portions.
• Smoking cessation and reducing alcohol intake.
• Elevating bed head, avoiding tight clothing.

2. Pharmacological Therapy:

• Proton Pump Inhibitor (PPI) Trial: Omeprazole or esomeprazole once daily for 4-8 weeks.
• Antacids or H2 blockers (ranitidine) for breakthrough symptoms.

3. Monitoring and Follow-Up:

• Review in 4-8 weeks.
• If symptoms persist despite lifestyle and PPI use, consider gastroscopy.

A stepwise approach ensures symptom control and prevention of complications.

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Q4: How would you educate Daniel on his diagnosis and long-term management?

Patient education is key to long-term symptom control.

1. Reassurance and Explanation:

• GORD is common and manageable with lifestyle and medication.
• Low risk of oesophageal cancer, but monitoring is important.

2. Long-Term Management:

• Identify and avoid triggers (e.g., diet, alcohol, smoking).
• Use PPIs correctly: Take before meals, reassess need periodically.
• Taper PPIs when symptoms improve to avoid long-term risks.

3. Follow-Up and When to Seek Help:

• Persistent symptoms despite treatment → Review for escalation.
• New red flag symptoms → Urgent referral.

Empowering the patient with knowledge and strategies improves adherence and outcomes.

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Q5: Daniel returns in three months with persistent symptoms despite lifestyle changes and PPI therapy. What would you do next?

Daniel’s persistent symptoms require further evaluation and management escalation.

1. Assess for PPI Failure:

• Confirm adherence: Is he taking PPIs 30 minutes before meals?
• Optimise therapy: Increase to twice daily dosing for 4-8 weeks.

2. Consider Differential Diagnoses:

• Functional dyspepsia or non-acid reflux.
• Oesophageal motility disorder.
• Biliary or peptic ulcer disease.

3. Indications for Referral to Gastroenterologist:

• Persistent symptoms despite optimised therapy.
• Recurrent regurgitation or nocturnal reflux.
• Suspected Barrett’s oesophagus (GORD >5 years, overweight, male).

4. Alternative Treatments:

• H2 receptor antagonists (ranitidine) or prokinetics.
• Consider anti-reflux surgery (fundoplication) in severe refractory cases.

Early specialist input prevents long-term complications and improves quality of life.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking covering symptoms, lifestyle, and red flags.
• Judicious use of investigations, considering gastroscopy if indicated.
• Stepwise management with lifestyle, PPI therapy, and monitoring.
• Effective patient education about triggers, long-term management, and follow-up.
• Timely referral for persistent or atypical symptoms.

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PITFALLS

• Failing to assess red flags, delaying investigation of serious pathology.
• Not optimising PPI use, leading to inadequate symptom control.
• Over-reliance on medication without addressing lifestyle factors.
• Delaying specialist referral in refractory or high-risk cases.
• Inadequate patient education, leading to poor adherence and recurrence.

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REFERENCES

• RACGP – RACGP Guidelines on GORD Management
• GP Exams – Oesophagus disease (GORD)

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD