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Gastro-oesophageal Reflux Disease J002

Last amended 
3 June 2021
Current RMA Instruments
Reasonable Hypothesis SOP
61 of 2021
Balance of Probabilities SOP
62 of 2021
Changes from previous instruments

SOP Bulletin 222

ICD Coding
  • ICD-9-CM:  530.11,530.2,530.81
  • ICD-10-AM: K21
   Brief description

This SOP covers gastric reflux of sufficient severity to either cause chronic inflammation of the oesophagus (with histological evidence), or to result in symptoms sufficient to warrant regular medical treatment. Minor symptomatic reflux without oesophagitis is very common, but is not a disease.

Confirming the diagnosis

The diagnosis is based on the clincial presentation (significantly symptomatic reflux) and is preferrably confirmed by upper gastrointestinal endoscopy, with histology.  Symptoms may involve the oesophagus (particularly heart burn) but may also include manifestations in the larynx and pharynx (regurgitation, cough, hoarseness).

The relevant medical specialist is a gastroenterologist.

Additional diagnoses covered by SOP
  • Reflux oesophagitis
  • Reflux with oseophageal ulceration
Related conditions that may be covered by SOP (further information required)
  • Heartburn
  • Waterbrash
  • Oesophagitis unspecified
Conditions not covered by SOP
  • Barrett’s oesophagus*
  • Oesophagitis due to radiation, infectious agents or corrosive agents#
  • Oesophageal varices#

* Another SOP applies

# non-SOP condition

Clinical onset

An accurate clinical onset may be difficult to establish.  Once the diagnosis has been confirmed and other causes of heartburn-type symptoms have been excluded, clinical onset can be backdated to when reflux symptoms of sufficient severity to warrant treatment first developed.

Clinical worsening

Permanent clinical worsening could be manifest by a persisting increase in the level of symptoms or the development of oesophageal ulcer, bleeding or stricture.  Barrett's oesophagus is a separate condition, not a worsening of GORD.