What is the next step for a patient with heartburn and abdominal pain unrelieved by antacids?

Next Step: Empirical PPI Trial

For a patient with heartburn and abdominal pain unrelieved by antacids and no alarm symptoms, the next step is to initiate a 4-8 week trial of single-dose proton pump inhibitor (PPI) therapy, not immediate endoscopy or H. pylori testing. 1

Rationale for PPI Trial First

The most recent AGA guidelines (2022) clearly recommend that patients presenting with typical reflux symptoms (heartburn and abdominal pain) without alarm symptoms should receive an empirical trial of single-dose PPI therapy for 4-8 weeks before proceeding to diagnostic testing. 1 This approach is:

• More cost-effective and safer than immediate endoscopy in low-risk patients 1
• Appropriate when antacids have failed, as antacids provide only temporary symptomatic relief and do not address the underlying acid-related pathology 1
• Diagnostic and therapeutic, as response to PPI therapy helps confirm acid-related etiology 1

When to Consider H. pylori Testing vs. Endoscopy

H. pylori Testing Approach

The 2002 Gut guidelines suggest that H. pylori test-and-treat strategy is appropriate for patients who have had symptoms for 4 weeks or longer in low-risk populations, but this is primarily for dyspepsia management and should follow failed PPI therapy in the context of heartburn. 1

Immediate Endoscopy is Reserved For:

• Alarm symptoms present (dysphagia, weight loss, bleeding, anemia) 1
• Failure to respond to PPI trial after 4-8 weeks 1
• Patients on chronic NSAIDs requiring evaluation 1
• Age-dependent thresholds based on local gastric cancer incidence 1

Practical Management Algorithm

Step 1: Initiate PPI Therapy

• Start omeprazole 20 mg once daily (or equivalent PPI) taken before meals 1, 2
• Continue for 4-8 weeks 1
• Antacids may be used concomitantly for breakthrough symptoms 2

Step 2: Assess Response at 4-8 Weeks

If symptoms resolve:

• Wean to lowest effective dose 1
• Consider on-demand therapy if symptoms remain controlled 1

If partial or no response:

• Assess compliance first 1
• Increase to twice-daily PPI (e.g., omeprazole 20 mg twice daily) 1
• Alternatively, switch to a more potent acid suppressive agent 1
• Reassess after another 4-8 weeks 1

If still no response after optimization:

• Proceed to endoscopy 1
• If endoscopy shows no erosive disease (Los Angeles B or greater) or Barrett's esophagus, perform prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm or rule out GERD 1

Common Pitfalls to Avoid

Don't Rush to Endoscopy

Immediate referral for endoscopy without a PPI trial is not indicated in the absence of alarm symptoms and represents overutilization of resources. 1 The 2022 AGA guidelines specifically emphasize that empirical PPI therapy should precede diagnostic testing in typical presentations. 1

Don't Test for H. pylori First in Heartburn-Predominant Symptoms

While H. pylori testing has a role in dyspepsia management, heartburn as the predominant symptom suggests GERD, which is acid-related rather than H. pylori-related. 1 The 2002 guidelines note that "patients with heartburn should, theoretically, have been identified on initial diagnosis and treated as GORD patients" rather than pursuing H. pylori testing first. 1

Ensure Adequate PPI Dosing and Timing

• PPIs must be taken before meals for optimal efficacy 2
• Many treatment failures are due to inadequate dosing or poor compliance rather than true PPI resistance 1
• If symptoms persist, verify the patient is taking the medication correctly before escalating to endoscopy 1

Why Not Option A (Immediate Endoscopy)?

Immediate gastroenterology referral for endoscopy is premature in this clinical scenario because:

• No alarm symptoms are present 1
• Empirical PPI therapy has not been attempted 1
• Most patients with typical reflux symptoms respond to PPI therapy without needing endoscopy 1
• Endoscopy is reserved for PPI non-responders or those with alarm features 1

Why Not Option B (H. pylori Test)?

While H. pylori testing has value in certain dyspepsia presentations, it is not the next step here because:

• Heartburn is the predominant symptom, suggesting GERD rather than peptic ulcer disease 1
• H. pylori eradication provides no clinically significant benefit in functional dyspeptics at one year 1
• The primary issue is acid-related symptoms that should respond to PPI therapy 1
• H. pylori testing becomes relevant if PPI therapy fails and endoscopy reveals ulcer disease 1