When should I refer a patient with controlled Gastroesophageal Reflux Disease (GERD) on Proton Pump Inhibitor (PPI) and negative Helicobacter pylori (H. pylori) test?

When to Refer a Patient with Controlled GERD on PPI and Negative H. pylori

For patients with GERD symptoms well-controlled on PPI therapy and negative H. pylori, referral to gastroenterology is generally not necessary unless specific high-risk features or complications develop. 1

Continue Current Management Without Referral If:

• Symptoms remain well-controlled on current PPI dose with no alarm features or complications 1
• Patient has not undergone endoscopy but lacks alarm symptoms (dysphagia, odynophagia, weight loss, bleeding, anemia) and is under age 55 1
• Attempt to wean PPI to the lowest effective dose or on-demand therapy after symptom control is achieved 1

Refer to Gastroenterology for Endoscopy When:

Alarm Features Present:

• Age ≥55 years with new-onset or persistent symptoms 1
• Dysphagia or odynophagia 1
• Unintentional weight loss 1
• Evidence of GI bleeding (hematemesis, melena, anemia) 1
• Persistent vomiting 1

Treatment Failure or Complications:

• Symptoms persist or recur despite 8-12 weeks of optimized twice-daily PPI therapy 1
• Patient requires chronic PPI therapy for >1 year without objective confirmation of GERD diagnosis 1
• Breakthrough symptoms on adequate PPI therapy requiring dose escalation or additional medications 1

Need for Diagnostic Confirmation:

• Patient has been on chronic PPI therapy without prior endoscopy or reflux testing to confirm GERD diagnosis and determine appropriateness of long-term therapy 1
• Consideration of anti-reflux surgery or endoscopic intervention in the future 1
• Atypical or extraesophageal symptoms (chronic cough, laryngitis, asthma) that persist despite PPI therapy 1

Special Considerations for Referral Timing:

For Patients on Long-Term PPI (>1 year):

• Refer for endoscopy and/or ambulatory pH monitoring off PPI to objectively confirm GERD diagnosis and justify continued therapy 1
• This prevents unnecessary long-term PPI use in patients who may have functional disorders rather than true GERD 1

For Patients Unable to Wean PPI:

• If symptoms immediately recur when attempting to reduce PPI dose, refer for reflux testing to confirm pathologic GERD before committing to indefinite therapy 1
• Patients with true erosive esophagitis (Los Angeles Grade B or higher) or Barrett's esophagus require indefinite PPI therapy and do not need weaning attempts 1, 2

Common Pitfalls to Avoid:

• Do not continue empiric PPI therapy indefinitely without objective confirmation of GERD, especially in patients who have never had endoscopy 1
• Do not assume PPI response confirms GERD diagnosis—up to 19% of PPI responders have normal pH monitoring and may have functional disorders 3
• Do not delay referral in patients ≥55 years even if symptoms are controlled, as endoscopy is indicated to exclude malignancy 1
• H. pylori status does not influence the decision to refer for GERD evaluation, as the infection does not significantly affect GERD management 4, 5

Algorithm for Referral Decision:

Step 1: Assess for alarm features (age ≥55, dysphagia, weight loss, bleeding) → If present, refer immediately 1

Step 2: If symptoms controlled on PPI, attempt to wean to lowest effective dose or on-demand therapy → If successful, continue primary care management 1

Step 3: If unable to wean or symptoms recur, and patient has been on PPI >1 year without prior endoscopy → Refer for diagnostic confirmation 1

Step 4: If symptoms persist despite optimized twice-daily PPI for 8-12 weeks → Refer for endoscopy and reflux testing 1