When to start medication and order an Esophagogastroduodenoscopy (EGD) for Gastroesophageal Reflux Disease (GERD)?

GERD: When to Start Medication and Order EGD

Start PPI therapy immediately for patients with troublesome heartburn, regurgitation, or non-cardiac chest pain without alarm symptoms—no testing needed first—and reserve EGD for those with alarm symptoms, PPI failure after 4-8 weeks, or when considering long-term therapy beyond 12 months. 1

When to Start Medication

Immediate PPI Trial (No Testing Required)

• Begin a 4-8 week trial of single-dose PPI therapy for any patient presenting with typical GERD symptoms (heartburn, regurgitation, non-cardiac chest pain) who lacks alarm symptoms. 1
• Take PPI 30-60 minutes before a meal for optimal efficacy. 1, 2
• Any commercially available PPI is acceptable (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, dexlansoprazole)—choice can be guided by cost and insurance coverage. 1, 2
• Emphasize PPI safety to patients and provide educational materials on GERD mechanisms, weight management, and lifestyle modifications. 1

Response Assessment at 4-8 Weeks

• If adequate response: Taper to the lowest effective dose for maintenance. 1
• If inadequate response: Increase to twice-daily dosing OR switch to a more potent acid suppressive agent. 1

When to Order EGD

Immediate EGD Indications (Before PPI Trial)

• Presence of alarm symptoms: dysphagia, bleeding, anemia, weight loss, recurrent vomiting. 2, 3
• Isolated extra-esophageal symptoms (chronic cough, hoarseness, throat clearing) with suspected reflux—perform upfront objective testing rather than empiric PPI trial. 1

EGD After Failed PPI Trial

• Order EGD when troublesome symptoms persist despite 4-8 weeks of optimized PPI therapy (including twice-daily dosing). 1, 4
• If endoscopy shows Los Angeles grade B or higher esophagitis or long-segment Barrett's esophagus (≥3 cm), GERD is confirmed. 1
• If endoscopy is normal or shows only LA grade A esophagitis, perform prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm or rule out GERD. 1

EGD for Long-Term PPI Users

• If PPI therapy continues beyond 12 months in a patient with unproven GERD, offer endoscopy with prolonged wireless reflux monitoring off PPI to establish appropriateness of long-term therapy. 1
• This is particularly important for shared decision-making about lifelong maintenance therapy. 1

Complete Endoscopic Evaluation Must Include

• Grading of erosive esophagitis (Los Angeles classification). 1
• Assessment of diaphragmatic hiatus (Hill grade) and hiatal hernia length. 1
• Inspection for Barrett's esophagus (Prague classification with biopsy if present). 1

Critical Pitfalls to Avoid

• Do not perform routine EGD for uncomplicated GERD with typical symptoms—empiric PPI trial is appropriate first-line management. 3
• Do not continue empiric PPI indefinitely without objective confirmation of GERD diagnosis, especially if symptoms persist. 4, 2
• Do not obtain biopsies from endoscopically normal tissue to diagnose GERD or exclude Barrett's esophagus. 3
• Verify proper PPI administration (30-60 minutes before meals) before escalating therapy or ordering invasive testing. 1, 4, 2

Special Populations Requiring Lower Threshold for EGD

• Patients over 50 years with significant smoking history are at increased risk for Barrett's esophagus and should undergo endoscopy. 4
• Consider endoscopy in patients with multiple risk factors for Barrett's esophagus. 3