Gastro oesophageal reflux disease or heart burn disease
Gastro-oesophageal reflux disease (GORD) or heart burn disease is a common condition, where acid from the stomach leaks up into the oesophagus (gullet).
It usually occurs as a result of the ring of muscle at the bottom of the oesophagus becoming weakened.
Causes of GORD
Gastro-oesophageal reflux disease (GORD) is usually caused by the ring of muscle at the bottom of the oesophagus (gullet) becoming weakened.
Normally, this ring of muscle opens to let food into your stomach and closes to stop stomach acid leaking back up into your oesophagus.
But for people with GORD, stomach acid is able to pass back up into the oesophagus. This causes symptoms of GORD, which can include heartburn and acid reflux.
It's not always clear what causes this ring of muscle to become weakened, but certain things can increase the risk of it happening (see below).
Who's most at risk of GORD?
The following factors may increase your risk of developing GORD:
being overweight or obese – this can place increased pressure on your stomach and weaken the muscles at the bottom of the oesophagus
Eating large amounts of fatty foods – the stomach takes longer to get rid of stomach acid after digesting a fatty meal and the resulting excess acid may leak up into the oesophagus
Smoking, alcohol, coffee or chocolate– these may relax the muscles at the bottom of the oesophagus
Pregnancy – temporary changes in hormone levels and increased pressure on your stomach during pregnancy can cause GORD (read more about heartburn in pregnancy)
Hiatus hernia – when part of your stomach pushes up through your diaphragm (thin sheet of muscle between the chest and tummy)
Gastroparesis – when the stomach takes longer to get rid of stomach acid, which means excess acid can leak up into the oesophagus
Certain medicines – some medicines can cause GORD or make the symptoms worse, including calcium-channel blockers (used to treat high blood pressure), nitrates (used to treat angina) and non-steroidal anti-inflammatory drugs (NSAIDs)
Stress
GORD can sometimes affect several members of the same family and it's been suggested that the genes you inherit from your parents may also affect your chances of developing the condition.
GORD causes symptoms such as heartburn and an unpleasant taste in the back of the mouth. It may just be an occasional nuisance for some people, but for others it can be a severe, lifelong problem.
GORD can often be controlled with self-help measures and medication. Occasionally, surgery to correct the problem may be needed.
This topic focuses on GORD in adults.
There are separate topics on reflux in babies and heartburn in pregnancy
Symptoms of GORD
Symptoms of GORD can include:
Heartburn (an uncomfortable burning sensation in the chest that often occurs after eating)
Acid reflux (where stomach acid comes back up into your mouth and causes an unpleasant, sour taste)oesophagitis (a sore, inflamed oesophagus)
Bad breath bloating and belching feeling or being sick
Pain when swallowing and/or difficulty in swallowing
What to do if you have GORD
You can often control the symptoms of GORD by making some lifestyle changes and taking over-the-counter medication.
Treatments for GORD
The main treatments for GORD are:
Treating heartburn and GORD
Heartburn and gastro-oesophageal reflux disease (GORD) can often be treated with self-help measures and over-the-counter medicines.
If these don't help, your GP can prescribe stronger medication or refer you to a specialist to discuss whether surgery may be an option.
This page covers:
Self-help
You may find the following measures can help reduce heartburn and other symptoms of GORD:
Eat smaller and more frequent meals, rather than three large meals a day – don't eat or drink alcohol within three or four hours before going to bed, and avoid having your largest meal of the day in the evening.
Avoid anything you think triggers your symptoms – common triggers include coffee, chocolate, tomatoes, alcohol, and fatty or spicy food.
Don't wear tight clothing – clothes that are tight around your tummy may make your symptoms worse.
Raise the head of your bed by up to 20cm (8 inches) – placing a piece of wood or blocks underneath one end of your bed may reduce symptoms at night; don't just use extra pillows, as this can put a strain on your tummy.
Try to relax – stress can make heartburn and GORD worse, so learning relaxation techniques may help if you're often feeling stressed.
Maintain a healthy weight – if you're overweight, losing weightmay help reduce your symptoms.
Stop smoking – smoke can irritate your digestive system and may make your symptoms worse.
If you're taking medication for other health conditions, check with your GP to find out whether they could be contributing to your symptoms.
Different medicines may be available, but don't stop taking any prescribed medication without consulting your GP first.
Medication
A number of different medications can be used to treat symptoms of GORD.
Over-the-counter medicines
Over-the-counter heartburn and GORD medicines are available from pharmacies without a prescription. The main types are:
Antacids – these neutralise the effects of stomach acid
Alginates – these produce a coating that protects the stomach and oesophagus (gullet) from stomach acid
Low-dose proton-pump inhibitors and H2-receptor antagonists – see below for more information about these
These medicines aren't suitable for everyone, so you should check the leaflet first. Ask a pharmacist for advice if you're not sure.
Proton-pump inhibitors (PPIs)
If your symptoms don't get better despite trying self-help measures and over-the-counter medicines, your GP may prescribe a PPI. These work by reducing the amount of acid produced by your stomach.
You'll usually be given enough medication to last a month. Go back to your GP if they don't help or your symptoms return after treatment finishes. Some people need to take PPIs on a long-term basis.
The possible side effects of PPIs are usually mild.
They include headaches, diarrhoea or
constipation, feeling sick, abdominal (tummy) pain, dizziness and a rash.
Your GP will prescribe the lowest dose that they think will control your symptoms to reduce the risk of side effects.
H2-receptor antagonists (H2RAs)
If PPIs don't control your symptoms, a medicine known as a H2RA may be recommended for you to take alongside them on a short-term basis, or as an alternative.
Like PPIs, H2RAs reduce the amount of acid produced by your stomach.
Side effects of H2RAs are uncommon, but can include diarrhoea, headaches, dizziness, a rash and tiredness.
Surgery and procedures
Surgery may be an option if:
The above treatments don't help, aren't suitable for you, or cause troublesome side effectsyou don't want to take medication on a long-term basis
The main procedure used is called a laparoscopic Nissen fundoplication (LNF). Alternative techniques have been developed more recently, although these aren't yet widely available.
Laparoscopic Nissen fundoplication (LNF)
LNF is a type of laparoscopic or "keyhole" surgery. This means it's carried out using special surgical instruments inserted through small cuts (incisions) in the skin.
The procedure is used to tighten the ring of muscle at the bottom of the oesophagus, which helps to stop acid leaking up from the stomach. It's carried out in hospital under general anaesthetic.
Most people need to stay in hospital for two or three days after the procedure. Depending on your job, you may be able to return to work within three to six weeks.
For the first six weeks after surgery, you should only eat soft food, such as mince, mashed potatoes or soup. Some people experience problems with swallowing, belching and bloating after LNF, but these should get better with time.
Newer operations and procedures
In the last few years, several new techniques for treating GORD have been developed.
The National Institute for Health and Care Excellence (NICE) says these procedures appear to be safe, but not much is known about their long-term effects.
These techniques include:
Endoscopic injection of bulking agents – where special filler is injected into the area between the stomach and oesophagus to make it narrower.Endoluminal gastroplication – where folds are sown into the ring of muscles at the bottom of the oesophagus to restrict how far it can open.Endoscopic augmentation with hydrogel implants – where implants containing special gel are placed into the area between the stomach and oesophagus to make it narrower.
Endoscopic radiofrequency ablation – where a tiny balloon is passed down to the bottom of the oesophagus and electrodes attached to it are used to heat it and make it narrower.
Laparoscopic insertion of a magnetic bead band (LINX) – where a ring of magnetic beads are implanted around the lower part of the oesophagus to strengthen it and help keep it closed when not swallowing.
Self-help measures – this includes eating smaller but more frequent meals, avoiding any foods or drinks that trigger your symptoms, raising the head of your bed, and keeping to a healthy weight
Over-the-counter medicines – ask your pharmacist to recommend an antacid or an alginate
Stronger prescription medicines – including proton-pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs)
You may only need to take medication when you experience symptoms, although long-term treatment may be needed if the problem continues.
Surgery to stop stomach acid leaking into your oesophagus may be recommended if medication isn't helping, or you don't want to take medication on a long-term basis.
You don't necessarily need to see your GP if you only have symptoms occasionally. Ask your pharmacist for advice on treatments.
When to see your GP
Visit your GP if you're worried about your symptoms, or if:
you have symptoms several times a weekover-the-counter medications aren't helpingyour symptoms are severeyou have difficulty swallowingyou have possible signs of a more serious problem, such as persistent vomiting, vomiting bloodor unexplained weight loss
Your GP will usually be able to diagnose GORD based on your symptoms, although they may refer you for some tests.
Read more about diagnosing GORD.
Complications of GORD
A number of possible complications can occur as a result of having gastro-oesophageal reflux disease (GORD) for a long time.
Oesophageal ulcers
The stomach acid that leaks into the oesophagus in people with GORD can damage the lining of the oesophagus (oesophagitis), which can cause ulcers to form.
These ulcers can bleed, causing pain and making it difficult to swallow.
Medications used to treat GORD, such as proton pump inhibitors (PPIs), can help ulcers heal by reducing the amount of acid that leaks into the oesophagus. Read more about treatments for GORD.
Scarred and narrow oesophagus
Repeated damage to the oesophagus by stomach acid can also cause it to become scarred and narrowed.
This is known as oesophageal stricture and it can make swallowing difficult and painful.
If this happens, a procedure to widen the oesophagus using a small balloon or other widening device may be recommended.
Barrett's oesophagus
Repeated episodes of GORD can sometimes lead to changes in the cells in the lining of your lower oesophagus. This is known as Barrett's oesophagus.
It's estimated that about 1 in every 10 people with GORD will develop Barrett's oesophagus, usually after many years.
Barrett's oesophagus doesn't usually cause noticeable symptoms other than those caused by GORD.
However, there's a small risk that the changed cells could become cancerous in the future (see below). Your doctor may suggest having an endoscopy every few years to check for this.
Oesophageal cancer
It's estimated that 1 in every 10-20 people with Barrett's oesophagus will develop oesophageal cancer within 10-20 years.
Symptoms of oesophageal cancer include:
difficulty swallowingunexplained weight losspersistent indigestionhoarsenessa persistent cough and/or coughing bloodvomiting
Speak to your doctor if you experience any swallowing difficulties, or any other unusual or persistent symptoms.
Surgery to remove the cancer can be carried out if it's diagnosed at an early stage.
If you have GORD for a long time, stomach acid can damage your oesophagus and cause further problems.
These include:
Ulcers (sores) on the oesophagus – these may bleed and make swallowing painful
The oesophagus becoming scarred and narrowed – this can make swallowing difficult and may require an operation to correct it
Changes in the cells lining the oesophagus (Barrett's oesophagus) – very occasionally, oesophageal cancer can develop from these cells, so you may need to be closely monitored
The main treatments for oesophageal cancer are surgery, chemotherapy and radiotherapy.
This page covers:
Your treatment plan
You'll be cared for by a group of different healthcare professionals and your team will recommend a treatment plan they feel is most suitable for you (see below), although final treatment decisions will be yours.
Your plan will largely depend on how far your cancer has spread – known as the "stage".
Stage 1-3 oesophageal cancer is usually treated with surgery to remove the affected section of oesophagus (oesophagectomy). Chemotherapy and sometimes radiotherapy may be given before surgery to make it more effective or is sometimes used instead of surgery.
Stage 4 oesophageal cancer has usually spread too far for a cure to be possible, but chemotherapy, radiotherapy and other treatments can slow the spread of the cancer and relieve symptoms.
The main treatments for oesophageal cancer are surgery, chemotherapy and radiotherapy.
This page covers:
Surgery
There are three main types of surgery for oesophageal cancer.
Oesophagectomy
An oesophagectomy is the main treatment for early stage oesophageal cancer.
During the procedure, your surgeon will remove the section of your oesophagus that contains the tumour and, if necessary, the nearby lymph nodes. A small portion of your stomach may also need to be removed.
The remaining section of your oesophagus is then reconnected to your stomach.
To access your oesophagus, your surgeon will either make incisions (cuts) in your tummy and chest, or in your tummy and neck.
Endoscopic mucosal resection (EMR)
A procedure called endoscopic mucosal resection (EMR) may sometimes be an option instead of an oesophagectomy if oesophageal cancer is diagnosed very early on.
It involves cutting out the tumour using a loop of wire at the end of a thin flexible tube (endoscope). The endoscope is passed down your throat so no incisions are made in your skin.
Sometimes radiowaves may also be used to destroy the cancerous tissue (called radiofrequency ablation or RFA).
Stents
For more advanced cases of oesophageal cancer that are causing swallowing difficulties, a procedure to insert a hollow tube called a stent into the oesophagus may be recommended.
The stent expands once in place and holds the oesophagus open.
Chemotherapy
Chemotherapy involves taking medicines that kill the cancer cells or stop them multiplying.
It may be used:
before and sometimes after surgery, either with or without radiotherapy – to shrink the cancer and reduce the risk of it coming backinstead of surgery – in combination with radiotherapy (called chemoradiation)to relieve your symptoms if curative treatment isn't possible
The medicines can be given into a vein or taken as tablets. You'll usually have the treatment every three weeks over a period of 6-18 weeks.
Side effects
Common side effects of chemotherapy include:
Feeling sickloss of appetitelosing weight
Diarrhoea feeling very tiredincreased risk of infectionsbleeding and bruising easily
These side effects should improve gradually after treatment stops. Read more about the
Side effects of chemotherapy
It's difficult to predict exactly what side effects you'll experience while having chemotherapy. Different people react to treatment in different ways.
A small number of people have very few or even no side effects.
Many of the common side effects of chemotherapy are listed below, although it's unlikely that you'll experience them all.
Your care team is there to help you cope with the physical and psychological side effects.
When to get urgent medical advice
While the side effects of chemotherapy can be distressing, most don't pose a serious threat to your health.
However, occasionally, some side effects can be very serious. For example, if you have a rapid fall in white blood cells, you may be vulnerable to a serious infection.
People having chemotherapy for cancer of the blood cells or bone marrow are most at risk of developing serious infections. This is because this type of cancer will already have caused a reduction in the number of white blood cells.
Symptoms of a serious problem include:
A high temperature of 38C (100.4F) or aboveshiveringbreathing difficultieschest painflu-like symptoms – such as muscle aches and painbleeding gums or nosebleeding from other parts of the body that doesn't stop after applying pressure for 10 minutes mouth ulcers that stop you eating or drinkingvomiting that continues, despite taking anti-sickness medicationfour or more bowel movements a day, or diarrhoea
Contact your care team immediately if you have any of these symptoms. Your care team should give you a card with 24-hour emergency phone numbers.
Call NHS 111 if you don't have a card or you can't find it.
Fatigue
Fatigue or tiredness is a common side effect of chemotherapy. Almost everyone who has chemotherapy will experience fatigue. You may feel generally tired or you may tire very easily after doing normal, everyday tasks.
While having chemotherapy, it's important to get plenty of rest. Don't carry out tasks or activities that you don't feel up to.
Light exercise, such as walking or yoga, can boost your energy levels, but be careful not to push yourself too hard.
If you're working, you may need to ask your employer to let you work part time until your chemotherapy has finished.
Read more about coping with the effects of tiredness and fatigue.
Contact your care team if you're suddenly significantly more tired than usual and you also feel out of breath. Extreme fatigue and shortness of breath can be a sign of anaemia (see below).
Nausea and vomiting
Nausea and vomiting are common side effects of chemotherapy. They affect around half of all people being treated.
If you experience nausea and vomiting, you'll be given medication to help control your symptoms. This type of medication is known as an anti-emetic.
Anti-emetics can be given in a number of different ways, including:
As a tablet or capsule – which can either be swallowed or placed under your tongue to dissolveas an injection or dripas a suppository – which is a capsule that you put into your bottom so that it can dissolvethrough a patch that you place on your skin
Continue taking your anti-emetics even if you don't feel sick, because they'll help stop your symptoms returning.
Side effects of anti-emetics include constipation, indigestion, problems sleeping (insomnia) and headaches.
There are several different types of anti-emetics. Contact your care team if the one you're taking doesn't work or if it causes too many troublesome side effects. There may be an alternative anti-emetic that works better for you.
Hair loss
Hair loss is a common side effect of some types of chemotherapy. It usually begins one to three weeks after the first chemotherapy dose, and most people have significant hair loss after one to two months.
The scalp is most commonly affected, although hair loss can also occur on other parts of your body, including your arms, legs and face.
Hair loss can be very traumatic, particularly for women. Talk to your care team if you find losing your hair very difficult to cope with. They understand how distressing it can be and will be able to give you support and counselling.
You may also find it useful to read more about coping with hair loss.
You may decide that you want to wear a wig. For some people, synthetic wigs are available free of charge on the NHS. Read more about wigs on the NHS.
Hair loss due to chemotherapy is almost always temporary, and your hair should begin to grow back soon after your treatment has finished.
Around three-quarters of people no longer wear a wig or use a head covering six months after their chemotherapy treatment has finished.
Many people find that their newly-grown hair is different than before. For example, it may be a different colour or it may be curlier or straighter than it used to be.
Cold cap
While receiving chemotherapy, it may be possible to prevent hair loss by using a cold cap. A cold cap looks similar to a bicycle helmet and is designed to cool your scalp while you receive a dose of chemotherapy. Cooling the scalp reduces the amount of blood flow to it, which reduces the amount of chemotherapy medication that reaches it.
Whether or not you can use a cold cap during treatment will depend on the type of cancer you have.
For example, a cold cap can't be used if you have:
Various types of leukaemia – such as acute lymphoblastic leukaemia, which is cancer of the blood cells and mainly affects children Multiple myeloma – which is a cancer that develops inside the bone marrow non-Hodgkin lymphoma – which is a cancer that develops inside the lymphatic system (a series of glands and vessels that help to protect the body against infection)
With these types of cancers, there's a good chance that cancerous cells could have spread to your skull. Therefore, it would be too dangerous to cool your skull.
Cold caps work better with certain types of chemotherapy medications, and they may not always prevent hair loss.
Increased risk of infection
Chemotherapy can reduce your body's ability to fight infection, so a course of antibiotics may be prescribed to reduce your risk of developing an infection.
You'll also need to take extra precautions to protect yourself against infection. For example, you should:
Have good personal hygiene – take daily baths or showers and make sure that your clothes, towels and bed linen are washed regularly
Avoid contact with people who have an infection – such as chickenpox or flu
Wash your hands regularly with soap and hot water – particularly after going to the toilet and before preparing food and eating
Take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it and cover it with a sterile dressing
Regular blood tests are often carried out during chemotherapy to identify when you are most vulnerable to infection.
You may be advised to take extra precautions, such as avoiding crowded places and using public transport at busy times.
Anaemia
Chemotherapy lowers the amount of red blood cells. These cells carry oxygen around the body. If your red blood cell count drops too low, your body will be deprived of oxygen and you'll develop anaemia.
Symptoms of anaemia include:
tiredness – you'll feel much more tired than the general level of fatigue associated with chemotherapylack of energyshortness of breath (dyspnoea)irregular heartbeat
Contact your care team as soon as possible if you have any of these symptoms.
You may need to have a blood transfusion to help increase the number of red blood cells. Alternatively, a medication called erythropoietin (EPO) can stimulate the production of red blood cells.
It's important to include a high amount of iron in your diet. This is because iron helps red blood cells to carry more oxygen. Foods that are high in iron include:
dark green leafy vegetablesiron-fortified breadbeansnutsmeatapricotsprunesraisins
Read more about treatment for anaemia.
Bruising and bleeding
Chemotherapy can make you more vulnerable to excessive bleeding and bruising. This can cause:
easily bruised skinnosebleeds bleeding gums
Report any of these symptoms to your care team, because you may need a blood transfusion to raise your platelet count.
Mucositis
In some cases, chemotherapy can cause pain and inflammation of the soft layer of tissue that lines the digestive system from the mouth to the anus (the mucous membrane). This is known as mucositis.
People having high-dose chemotherapy usually experience more severe symptoms.
The symptoms of mucositis usually begin 7 to 10 days after you start chemotherapy.
If you develop mucositis, the inside of your mouth may feel sore, as if you've burnt it by eating very hot food. You'll probably develop ulcers on the lining of your mouth and, in some cases, on your tongue or around your lips.
The ulcers can be very painful and make it difficult to eat, drink and talk. They may also bleed and become infected.
The symptoms of mucositis should clear up a few weeks after your chemotherapy finishes. Medication is available to relieve the symptoms.
Loss of appetite
If you lose your appetite, it's important to make an effort to eat healthily and drink plenty of liquids.
You may find eating smaller, more frequent meals better than eating three large meals a day. Try sipping drinks slowly through a straw, rather than drinking them straight from a glass.
If you have serious problems eating and drinking due to symptoms such as mouth ulcers, you may need to be admitted to hospital, so that you can be fed with a feeding tube.
Skin and nails
Some chemotherapy medications can cause your skin to become dry and sore, particularly on your hands or feet. Your nails may become brittle and flakier than usual, and white lines may develop across them.
During chemotherapy, and for some time after treatment has finished, your skin may become more sensitive to sunlight, so it's important to protect your skin from the sun.
Memory and concentration
Some people have problems with their short-term memory, concentration and attention span during chemotherapy. You may find that routine tasks take much longer than usual.
It's unclear why this happens, but the symptoms will usually improve after your treatment has finished.
Sleep problems
Sleep problems are a common side effect of chemotherapy. They're thought to affect around half of all people being treated with chemotherapy.
Sleep problems can include difficulty falling asleep (insomnia), and waking up in the middle of the night and being unable to get back to sleep.
The following advice may help to improve your sleep:
Go to bed only when you're sleepy.If you can't sleep, leave the bedroom and only return when you feel sleepy.Only use your bedroom for sleeping and having sex.Avoid napping during the day; if this isn't possible, try to limit your naps to about half an hour.Avoid stimulants, such as caffeine, for at least six hours before you plan to go to bed.
Contact your care team if this advice doesn't work, as you may need additional treatment. A type of therapy called cognitive behavioural therapy (CBT) has been shown to be effective in treating insomnia associated with chemotherapy.
Sexuality and fertility
Many people find that they lose interest in sex during chemotherapy. However, this is usually temporary and your interest in sex should gradually return after your treatment has finished.
Some chemotherapy medicines can stop women being able to conceive and can prevent men from producing healthy sperm. Loss of fertility is usually temporary, although it can be permanent in some cases.
If you're at risk of becoming permanently infertile, your care team can discuss this with you before treatment.
A number of options are available. Women can have their eggs frozen to be used later in IVF (in vitro fertilisation). Men can have a sample of their sperm frozen, to be used at a later date for artificial insemination.
Diarrhoea and constipation
You may have diarrhoea or constipation a few days after you begin chemotherapy. Your care team can recommend suitable medication to help control the symptoms.
Read more about treatment for diarrhoea and treatment for constipation.
Depression
Living with the effects of chemotherapy can be frustrating, stressful and traumatic. It's natural to feel ongoing anxiety and concern about whether your treatment will be successful.
Stress and anxiety can increase your risk of getting depression.
Contact your care team if you have psychological and emotional difficulties. They'll be able to recommend treatments to help improve the symptoms of stress, anxiety and depression.
Joining a support group for people who are having chemotherapy may also help. Talking to other people in a similar situation can often reduce feelings of isolation and stress.
The charity Macmillan Cancer Support has an online directory of cancer information and support centres in England. You can search the directory to find a centre in your area. You can also call the Macmillan Support Line free on 0808 808 00 00 (Monday to Friday, 9am-8pm).
Refusing or withdrawing treatment
In some circumstances, you may think that the benefits of chemotherapy aren't worth the poor quality of life, due to the side effects.
For example, if chemotherapy offers no hope of a cure and can only extend your life by a few months, you may feel that the extra few months aren't worth undergoing treatment.
However, if you are looking forward to an event such as the birth of a grandchild or the wedding of a son or daughter, you may want to extend your life, whatever the cost to your wellbeing.
There's no right answer or recommendation about when chemotherapy should be refused or withdrawn. Your care team can give you advice about the likely benefit of continuing with treatment, but the final decision will be yours.
This is obviously a very sensitive topic that you should discuss fully with your care team, family, friends and loved ones. You always have the right to refuse a particular treatment or to ask for the treatment to be stopped if you don't feel it's benefiting you.
Stopping chemotherapy doesn't mean that any symptoms you have will go untreated. Your care team will still provide support and pain relief. This type of care is known as palliative care.
If it's thought that you don't have long to live, it may be recommended that you're admitted to a hospice. Hospices provide care for people from the point at which their illness is diagnosed as terminal to the end of their life, however long that may be.
Read more about end of life care.
The Yellow Card Scheme allows you to report suspected side effects from any type of medicine you're taking. It's run by a medicines safety watchdog known as the Medicines and Healthcare Products Regulatory Agency (MHRA).
See the Yellow Card Scheme website for more information.
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