Workup for Heartburn (GERD)
For patients presenting with typical heartburn symptoms without alarm features, start with an empirical trial of single-dose PPI therapy for 4-8 weeks and reserve diagnostic testing for non-responders or those requiring long-term therapy. 1
Initial Clinical Assessment
Screen for alarm symptoms that mandate immediate endoscopy rather than empirical therapy: 1
- Troublesome dysphagia
- Unintentional weight loss
- Evidence of gastrointestinal bleeding
- Persistent vomiting
- Palpable mass or lymphadenopathy
Distinguish typical from atypical presentations: 1
- Typical symptoms (heartburn, acid regurgitation, non-cardiac chest pain): Proceed with empirical PPI trial
- Isolated extra-esophageal symptoms (chronic cough, laryngitis, asthma): Skip empirical therapy and proceed directly to objective reflux testing off medication 1
Empirical PPI Trial (First-Line for Typical Symptoms)
Initiate single-dose PPI therapy (e.g., omeprazole 20 mg once daily) taken 30-60 minutes before a meal for 4-8 weeks: 1, 2
Assess response at 4-8 weeks: 1
- Sustained symptom resolution: Wean to lowest effective dose or convert to on-demand therapy 1
- Partial or no response: Verify compliance, then escalate to twice-daily PPI (before breakfast and dinner) or switch to alternative acid suppressive agent 1
Reassess at 4-8 weeks after dose escalation: 1
- If symptoms persist despite optimized therapy, proceed to diagnostic workup rather than further empirical escalation 1
Diagnostic Testing (When Empirical Therapy Fails or Long-Term Use Anticipated)
Upper Endoscopy with Comprehensive Evaluation
Perform endoscopy in the following scenarios: 1
- Inadequate response to 4-8 weeks of twice-daily PPI therapy
- Presence of alarm symptoms at any point
- Need to confirm GERD diagnosis before committing to long-term PPI therapy (evaluate at 12 months if unproven GERD) 1
Complete endoscopic assessment must include: 1, 3
- Erosive esophagitis grading using Los Angeles classification (Grade B or higher confirms GERD)
- Barrett's esophagus assessment using Prague classification with biopsies when present
- Hiatal hernia measurement (axial length)
- Hill grade of gastroesophageal flap valve
- Evaluation for strictures or masses
Ambulatory pH Monitoring
Timing relative to PPI therapy depends on prior findings: 1
OFF PPI therapy (preferred for diagnosis): 1
- Use in patients without previous pathological endoscopic or pH findings
- Discontinue PPI for 2-7 days before testing 1
- Preferred method: 96-hour wireless pH monitoring (if available) 1
- Diagnostic criteria:
ON PPI therapy: 1
- Use in patients with previous pathological endoscopic or pH findings who remain symptomatic on twice-daily PPI
- Perform 24-hour pH-impedance monitoring to determine mechanism of persistent symptoms (inadequate acid suppression vs. non-acid reflux vs. functional disorder) 1, 2
Common Pitfalls to Avoid
Do not perform dual-probe proximal/distal pH monitoring for throat or respiratory symptoms—single distal probe is sufficient 1
Do not add nocturnal H2-receptor antagonists to twice-daily PPI therapy—no evidence supports improved efficacy with this combination 3
Do not continue empirical dose escalation indefinitely—patients failing twice-daily PPI warrant diagnostic evaluation, not further empirical treatment 1
Do not use symptom indices alone for symptoms other than heartburn, acid regurgitation, or chest pain—reproducibility is poor for other symptom types 1
Long-Term Management Considerations
For patients requiring chronic PPI therapy: 1
- Evaluate appropriateness and dosing within 12 months of initiation 1
- Consider reflux testing off PPI to establish need for lifelong therapy 1
- Emphasize PPI safety—short-term safety profile comparable to placebo 1, 4
Provide standardized patient education on: 1