What is the best course of action for a patient with persistent gastroesophageal reflux disease (GERD) symptoms, including heartburn and dysphagia, despite initial treatment?

Management of Persistent GERD with Dysphagia

This patient requires urgent upper endoscopy due to the alarm symptom of dysphagia (food getting caught in the throat), which mandates immediate investigation to rule out esophageal stricture, malignancy, or eosinophilic esophagitis. 1

Immediate Action Required

Upper endoscopy is indicated immediately for patients with GERD symptoms and dysphagia, as this is an alarm symptom that requires urgent evaluation regardless of PPI response. 1 The presence of food getting stuck represents a red flag that cannot be managed empirically. 1

What to Look for on Endoscopy

The complete endoscopic evaluation must assess: 1

• Erosive esophagitis (graded by Los Angeles classification) 1
• Esophageal stricture (peptic or malignant) 1, 2
• Barrett's esophagus (graded by Prague classification with biopsy if present) 1
• Hiatal hernia (Hill grade of flap valve and axial length) 1
• Eosinophilic esophagitis (requires mucosal biopsy even with normal appearance) 2

Optimize PPI Therapy While Awaiting Endoscopy

Escalate to twice-daily PPI therapy immediately if the patient is currently on once-daily dosing, as persistent heartburn indicates inadequate acid suppression. 1

• Take PPI 30-60 minutes before breakfast and dinner 3
• Standard dosing: omeprazole 20 mg twice daily or equivalent 3
• Do not exceed 8 weeks of empirical therapy without objective testing 1

Post-Endoscopy Management Algorithm

If Stricture is Found:

• Dilation is required for symptomatic relief 1
• Continue twice-daily PPI therapy after dilation 1
• Patients with history of stricture need endoscopy only if dysphagia recurs, not routinely 1

If Severe Erosive Esophagitis (LA Grade C or D):

• Continue twice-daily PPI for 8 weeks 1
• Repeat endoscopy after 2 months to confirm healing and rule out Barrett's esophagus 1
• Transition to long-term maintenance PPI at lowest effective dose 1

If Normal Endoscopy or Mild Esophagitis:

• Perform prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm GERD and phenotype the disease 1
• This distinguishes true PPI-refractory GERD from functional heartburn or reflux hypersensitivity 1

Addressing the Dysphagia Specifically

Dysphagia with GERD has three main causes that endoscopy will differentiate: 2

1. Peptic stricture from chronic acid exposure (requires dilation) 1
2. Eosinophilic esophagitis (requires biopsy and different treatment approach) 2
3. Esophageal dysmotility (requires high-resolution manometry if endoscopy is normal) 1, 2

If endoscopy is normal but dysphagia persists, high-resolution manometry is mandatory to rule out achalasia or other motor disorders before attributing symptoms to GERD. 1, 2

Lifestyle Modifications to Emphasize Now

While awaiting endoscopy, implement these evidence-based interventions: 1

• Weight loss if BMI >25 (strongest evidence for symptom improvement) 1
• Elevate head of bed 6-8 inches for nighttime symptoms 1
• Avoid meals within 3 hours of bedtime 1
• Eliminate trigger foods identified by patient history 1

Common Pitfalls to Avoid

Do not continue empirical PPI therapy beyond 12 months without objective confirmation of GERD via endoscopy and pH monitoring. 1 This patient has already failed initial therapy and has an alarm symptom, making continued empirical treatment inappropriate. 1

Do not assume dysphagia will resolve with PPI optimization alone. Dysphagia requires mechanical evaluation regardless of acid suppression adequacy. 1

Do not add prokinetics empirically. These have no proven benefit in GERD unless gastroparesis is documented. 1

If Symptoms Persist After Endoscopy and Optimized Medical Therapy

Consider pH-impedance monitoring on PPI therapy to determine the mechanism of persistent symptoms: 1

• Confirms PPI-refractory GERD (ongoing acid exposure despite therapy) 2
• Identifies reflux hypersensitivity (normal acid exposure but symptom correlation) 1
• Detects behavioral disorders (rumination, supragastric belching) 1

Surgical or endoscopic intervention (laparoscopic fundoplication, magnetic sphincter augmentation, or transoral incisionless fundoplication) should be considered for proven GERD with persistent regurgitation despite optimized PPI therapy, particularly in carefully selected patients with documented hiatal hernia and intact esophageal motility. 1