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Typical heartburn/regurgitation only, presumed GERD Empiric PPI trial1 recommended [S/M] - If typical heartburn and regurgitation: presumptive GERD dx can be established
- Treat empirically w/ PPI2
- If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy3 recommended
- Not recommended: ambulatory esophageal reflux monitoring,4 barium radiographs5 [S/H], esophageal manometry [S/L], H. pylori screen [S/L]
Footnotes 1 A negative PPI trial does not r/o GERD.
2 PPI once-daily dosing, before 1st meal of day [S/M].
3 Upper endoscopy not required for typical GERD sx [S/M]. Consider endoscopy early for elderly, pts at risk for Barrett’s, noncardiac chest pain, and pts unresponsive to PPI. Consider screening for Barrett’s in high-risk pts (long GERD duration, age >50 yo, male, Caucasian) [C/M]. Routine distal esophagus bx not recommended specifically to dx GERD [S/M].
4 Ambulatory esophageal reflux monitoring indicated in situations when GERD dx is in question [S/L]; it’s the only test that can assess reflux-to-symptom association [S/L].
5 Use barium swallow for eval of dysphagia or GERD complication (stricture, ring).
Extraesophageal sx (asthma, cough, laryngitis) w/o chest pain Carefully evaluate for non-GERD causes in all pts [S/M] - If typical GERD sx also present: consider PPI6 trial7 [S/L]
- If no typical GERD sx: reflux monitoring8 prior to PPI trial [C/L]
- If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy9 recommended
- Not recommended: esophageal manometry [S/L], H. pylori screen [S/L], barium radiographs [S/H]
If extra-esophageal sx persist despite PPI optimization:10 - Concomitant evaluation by ENT, pulmonary, and allergy specialists9 [S/L]
- If refractory GERD after these evals negative: ambulatory reflux8,11 monitoring [S/L]
- For typical GERD sx nonresponsive to PPI: endoscopy9 to exclude non-GERD etiologies [C/L]
Footnotes 6 PPI once-daily dosing, before 1st meal of day [S/M].
7 A negative PPI trial does not r/o GERD.
8 Reflux monitoring off meds by either pH or impedance-pH [C/M]; if on meds, should be performed w/ impedance-pH monitoring [S/M].
9 Upper endoscopy not recommended to establish dx of GERD-related asthma, cough, laryngitis [SL]. Reflux laryngitis dx should not be based solely on laryngoscopy [S/M]. Upper endoscopy not required for typical GERD sx [S/M]. Consider endoscopy early for elderly, pts at risk for Barrett’s, noncardiac chest pain, and pts unresponsive to PPI. Consider screening for Barrett’s in high-risk pts (long GERD duration, age >50 yo, male, Caucasian) [C/M]. Routine distal esophagus bx not recommended specifically to dx GERD [S/M].
10 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M]. Optimize PPI: increase PPI dosing to bid or consider a switch to a different PPI [C/L]. If nocturnal sx, sleep disturbance, and/or variable schedules: consider dose-timing adjustment and/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI tx in pts w/ nighttime sx, but tachyphylaxis may occur after several wks of use [C/L]. If PPI side-effects: switch PPIs [C/L].
11 Ambulatory esophageal reflux monitoring indicated in situations when GERD dx is in question [S/L]; it’s the only test that can assess reflux-to-symptom association [S/L].
Noncardiac chest pain suspected as GERD Exclude cardiac cause prior to GI eval [S/L] - After r/o cardiac cause: pts w/ noncardiac chest pain should have diagnostic eval before instituting tx [C/M]; consider dx eval w/ endoscopy12 + pH monitoring, before a PPI trial.13
Footnotes 12 A systematic review suggests that response of noncardiac chest pain to PPI trial was significantly higher vs placebo in pts w/ objective GERD evidence (endoscopy and/or pH monitoring), while response vs placebo was almost nonexistent in absence of objective GERD documentation.
13 Do not initiate tx before diagnostic eval [C/M]. Consider endoscopy early for elderly, pts at risk for Barrett’s, noncardiac chest pain, and pts unresponsive to PPI. If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy recommended.
Ambulatory reflux monitoring is indicated [S/L] - Reflux monitoring off meds can be performed by either pH or impedance-pH [C/M]. Testing on meds should be performed w/ impedance-pH monitoring [S/M].
- Ambulatory reflux monitoring is the only test that can assess reflux-to-symptom association [S/L]
- If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy14 recommended
Footnotes 14 Upper endoscopy not required for typical GERD sx [S/M]. Consider screening for Barrett’s in high-risk pts (long GERD duration, age >50 yo, male, Caucasian) [C/M]. Consider endoscopy early for elderly, pts at risk for Barrett’s, noncardiac chest pain, and pts unresponsive to PPI.
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First, optimize PPI dose, timing, and drug.15 Then refer PPI nonresponders for eval [C/L]: - If typical/dyspeptic sx PPI-refractory: upper endoscopy16 to r/o non-GERD etiologies [C/L]; if endoscopy negative: ambulatory reflux17 monitoring [S/L]; if tests negative: unlikely to have GERD, so discontinue PPI [S/L]
- If extra-esophageal sx persist despite PPI optimization: concomitant evaluation by ENT, pulmonary, and allergy specialists [S/L]; if refractory after these evals negative: ambulatory reflux17 monitoring [S/L]
- If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy16 recommended
- Not recommended: esophageal manometry [S/L], H. pylori screen [S/L], barium radiographs [S/H]
Footnotes 15 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M]. Optimize PPI: increase PPI dosing to bid or consider a switch to a different PPI [C/L]. If nocturnal sx, sleep disturbance, and/or variable schedules: consider dose-timing adjustment and/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI tx in pts w/ nighttime sx, but tachyphylaxis may occur after several wks of use [C/L]. If PPI side-effects: switch PPIs [C/L]. PPI switching is common in practice; there are limited data to support this; no data to support switching PPIs ≥1x in partial/nonresponders. Meta-analyses fail to show significant efficacy difference for sx relief between PPIs.
16 Upper endoscopy not recommended to establish dx of GERD-related asthma, cough, laryngitis [SL]. Reflux laryngitis dx should not be based solely on laryngoscopy [S/M]. Consider endoscopy early for elderly, pts at risk for Barrett’s, noncardiac chest pain, and pts unresponsive to PPI. Consider screening for Barrett’s in high-risk pts (long GERD duration, age >50 yo, male, Caucasian) [C/M]. Routine distal esophagus bx not recommended specifically to dx GERD [S/M].
17 Ambulatory esophageal reflux monitoring indicated in eval of PPI-refractory pts and in situations when GERD dx is in question [S/L]; it’s the only test that can assess reflux-to-symptom association [S/L]. Reflux monitoring off meds by either pH or impedance-pH [C/M]; if on meds, should be performed w/ impedance-pH monitoring [S/M].
Optimize PPI dose, timing, and drug18 - If nocturnal sx, sleep disturbance, &/or variable schedules: consider dose-timing19 adjustment &/or bid dosing [S/L]. Bedtime H2RA can be added prn to daytime PPI tx for nighttime sx, but tachyphylaxis may occur after several wks of use [C/L].
- Increase PPI dosing19 to bid or consider a switch to a different PPI20 [C/L]
- If PPI side-effects: switch PPIs20 [C/L]
Footnotes 18 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M]. Optimize PPI: increase PPI dosing to bid or consider a switch to a different PPI [C/L]. If nocturnal sx, sleep disturbance, and/or variable schedules: consider dose-timing adjustment and/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI tx in pts w/ nighttime sx, but tachyphylaxis may occur after several wks of use [C/L]. If PPI side-effects: switch PPIs [C/L]. PPI switching is common in practice; there are limited data to support this; no data to support switching PPIs ≥1x in partial/nonresponders. Meta-analyses fail to show significant efficacy difference for sx relief between PPIs.
19 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M].
20 PPI switching is common in practice; there are limited data to support this; no data to support switching PPIs ≥1x in partial/nonresponders. Meta-analyses fail to show significant efficacy difference for sx relief between PPIs.
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