Chronic Cough: Hidden GORD

Clinical Scenario

Michael Davies, 30, calls because his cough is still not better and he is very worried. He has had a persistent dry cough for 3 months. Six weeks ago he was given amoxicillin by another GP, which made no difference. The cough is worse at night when lying down, worse after eating, and he sometimes wakes with a sour taste in his mouth. He has no wheeze, no breathlessness, no haemoptysis, and no weight loss. He is a non-smoker with no significant PMH. He is worried about lung cancer because a colleague at work was recently diagnosed.

What This Case Tests

Generating an appropriate differential diagnosis for chronic cough (over 8 weeks); identifying GORD as the likely cause based on specific clinical features (nocturnal worsening when supine, post-prandial exacerbation, sour taste); not prescribing further unnecessary antibiotics; addressing cancer anxiety in a low-risk patient; arranging appropriate management (PPI trial, lifestyle modification).

Common Mistakes Trainees Make

The three most common mistakes are: prescribing another course of antibiotics (the first course did not work because this is not an infection), not considering GORD as a cause of chronic cough (it is the third most common cause after post-nasal drip and asthma, but often overlooked), and not addressing the cancer anxiety (Michael's colleague's diagnosis is driving his worry, and this needs direct reassurance in a 30-year-old non-smoker).

The Consultation Challenge

Michael has a chronic cough — defined as lasting more than 8 weeks. The three most common causes in a non-smoker are post-nasal drip, cough-variant asthma, and gastro-oesophageal reflux disease (GORD). The clinical features here point strongly to GORD.

Take a systematic cough history. Duration: 3 months (chronic). Character: dry (no sputum). Timing: worse at night when supine, worse after meals. Associated features: sour taste in the morning. Aggravating factors: lying flat, eating. Relieving factors: sitting upright. Red flags absent: no haemoptysis, no weight loss, no breathlessness, no chest pain, non-smoker, age 30.

The pattern is classic for GORD-related cough. Acid refluxing into the oesophagus can trigger a vagal-mediated cough reflex without the patient experiencing typical heartburn. The nocturnal worsening when supine (acid flows more easily), post-prandial exacerbation (increased acid production after eating), and sour taste (acid reaching the oropharynx) are all characteristic.

Systematically exclude other common causes. Post-nasal drip: any nasal congestion, sneezing, throat clearing, or nasal discharge? (If absent, unlikely.) Cough-variant asthma: any wheeze, breathlessness, atopy history, diurnal variation, or exercise-induced symptoms? (If absent, unlikely, but spirometry can be arranged if clinical doubt.) ACE inhibitor cough: is he on any medications? (No — rules this out.) Pertussis: paroxysmal cough with whooping or post-tussive vomiting? (Not described.)

Address the cancer anxiety directly. "I can understand why your colleague's diagnosis has worried you. But I want to reassure you — at 30, as a non-smoker, with no haemoptysis, no weight loss, and a cough that has a clear pattern related to eating and lying down, lung cancer is extremely unlikely. What you are describing fits very well with a condition called acid reflux causing your cough."

Management: Start a PPI trial (omeprazole 20mg BD for 8 weeks — note the higher-than-standard dose for reflux cough). Lifestyle advice: avoid eating within 3 hours of bedtime, elevate the head of the bed, reduce caffeine and alcohol, smaller meals, avoid tight clothing. If the cough resolves with the PPI trial, this confirms the diagnosis. If it does not respond, consider alternative causes (cough-variant asthma — trial of inhaled corticosteroid) and arrange a chest X-ray if not already done.

Time check: Spend the first 4 minutes on the cough history and systematic differential. By minute 6, explain the GORD diagnosis. Address the cancer anxiety between minutes 7-8. Use minutes 9-11 for the management plan. Reserve the final minute for follow-up and safety netting.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you take a systematic chronic cough history covering the three common causes (post-nasal drip, asthma, GORD), identify the GORD-specific features (nocturnal worsening supine, post-prandial, sour taste), exclude red flags for serious pathology, and review the failed antibiotic course (confirming this is not infective). The diagnosis should be made from the history — not from investigation results.

Clinical Management and Medical Complexity: Examiners expect a PPI trial at the correct dose for reflux cough (omeprazole 20mg BD, not the standard 20mg OD), lifestyle modification advice, a plan for reassessment if the PPI trial fails (consider cough-variant asthma, arrange CXR), and crucially, no further antibiotics. Demonstrating that you withhold unhelpful treatment is as important as demonstrating what you prescribe.

Relating to Others: Examiners assess whether you address the cancer anxiety directly and with proportionate reassurance, explain the GORD mechanism in accessible terms (many patients do not connect acid reflux with coughing), and ensure Michael leaves understanding both the diagnosis and the treatment plan. The consultation should feel like a resolution — Michael has been worried for 3 months and finally has an explanation.

Example Opening

Strong opening: "Hello Michael, I can see this cough has been going on for a while and it is really bothering you. I want to get to the bottom of it today. Can you tell me everything about the cough — when it is worst, what makes it better or worse, and any other symptoms you have noticed?"

When explaining GORD-related cough: "I think I know what is causing your cough. The pattern you are describing — worse at night when you lie down, worse after eating, and that sour taste in the morning — is very typical of acid reflux irritating the nerves in your throat and triggering a cough. A lot of people are surprised that reflux can cause a cough without heartburn, but it is actually one of the most common causes."

When addressing cancer anxiety: "I know your colleague's diagnosis has been on your mind, and I completely understand that. But at 30, with no smoking history and no warning signs like coughing up blood or losing weight, lung cancer is extremely unlikely. What you have is a very treatable condition."

Avoid: "Let's try another course of antibiotics and see if that helps." (Repeating ineffective treatment wastes time and reinforces the wrong diagnosis).

How This Appears in the SCA

Chronic cough with a hidden cause tests your ability to generate a differential diagnosis beyond infection, identify GORD from clinical features alone, and avoid unnecessary antibiotics and investigation. The cancer anxiety adds a communication dimension. Examiners value trainees who diagnose positively from the history rather than ordering extensive tests.

Key Statistic

Chronic cough (lasting over 8 weeks) affects approximately 10% of adults. GORD accounts for approximately 20-40% of chronic cough cases. A therapeutic trial of high-dose PPI for 8 weeks is both diagnostic and therapeutic — cough improvement confirms the GORD diagnosis.

Relevant Guidelines

• NICE CG126: GORD and dyspepsia in adults
• British Thoracic Society guideline on investigation and management of chronic cough
• NICE CG198: Acute cough (illness in adults).

Frequently Asked Questions

What are the three most common causes of chronic cough in a non-smoker?

Post-nasal drip (upper airway cough syndrome), cough-variant asthma, and gastro-oesophageal reflux disease (GORD). Together these account for approximately 90% of chronic cough cases in non-smokers with a normal chest X-ray. A systematic history covering each of these three causes is the most efficient diagnostic approach and demonstrates strong clinical reasoning.

How does GORD cause cough without heartburn?

Acid refluxing into the oesophagus stimulates the vagus nerve, triggering a cough reflex. This can occur without the patient experiencing typical heartburn or acid taste — known as silent reflux or laryngopharyngeal reflux. The clinical clues are: cough worse when supine (acid flows more easily in the horizontal position), worse after meals (increased acid production), and sometimes a sour taste on waking. Recognising this pattern is the key diagnostic skill.

What dose of PPI should I prescribe for a reflux-related cough?

Higher than the standard reflux dose. Omeprazole 20mg twice daily (or lansoprazole 30mg twice daily) for a minimum of 8 weeks is recommended for reflux-related cough. The standard once-daily dose used for heartburn is often insufficient to suppress the acid enough to resolve the cough. If the cough improves, this confirms the GORD diagnosis. If it does not respond after 8 weeks, consider alternative causes.

When should I arrange a chest X-ray for chronic cough?

A chest X-ray is indicated if: the cough has not responded to treatment for a common cause (PPI trial, asthma treatment), red flags are present (haemoptysis, weight loss, breathlessness, smoking history, age over 50), the cough is associated with new respiratory signs, or there is no clear diagnosis after systematic assessment. In Michael's case — 30 years old, non-smoker, no red flags, classic GORD pattern — a chest X-ray is not the first priority but should be arranged if the PPI trial fails.

How do I address cancer anxiety in a low-risk patient with cough?

Acknowledge the fear directly: "I understand why you are worried, especially after your colleague's diagnosis." Then provide proportionate reassurance using specific clinical features: "At your age, as a non-smoker, with no blood in the sputum and no weight loss, lung cancer is extremely unlikely. The pattern of your cough — worse after eating and lying down — points to a very common and treatable condition." Specific reassurance is more effective than vague reassurance.