How to approach a patient with recurrent heartburn and what are the common differentials?

Approach to Recurrent Heartburn

Begin with a 4-8 week trial of single-dose PPI therapy (20 mg omeprazole or equivalent) taken 30-60 minutes before breakfast, combined with targeted lifestyle modifications based on the patient's specific symptom triggers. 1

Initial Clinical Assessment

Symptom Characterization:

• Typical esophageal symptoms (heartburn and regurgitation) are approximately 70% sensitive and specific for GERD, making empiric PPI therapy appropriate without upfront testing 1
• Assess for "troublesome" symptoms—those that adversely affect the patient's well-being—which distinguishes GERD from episodic physiologic reflux 1
• Screen for alarm symptoms (dysphagia, weight loss, bleeding, anemia) that mandate immediate endoscopy before empiric therapy 1, 2
• Determine timing: nocturnal symptoms are more troublesome, harder to treat, and may present with extraesophageal manifestations 3

Key Clinical Factors to Identify:

• Central obesity or known hiatal hernia (suggests mechanical reflux) 1
• Anxiety or stress-induced symptoms (suggests visceral hypersensitivity) 1
• Behavioral patterns like rumination or supragastric belching 1
• Connective tissue disorders (raises concern for esophageal dysmotility) 1

Common Differentials

Esophageal GERD Syndromes:

• Symptomatic GERD without esophageal injury (most common presentation) 1
• Erosive esophagitis (requires endoscopy for diagnosis) 1
• Barrett's esophagus (long-segment ≥3 cm is significant) 1
• Peptic stricture (presents with dysphagia) 4

Non-GERD Esophageal Conditions:

• Functional heartburn (does not meet Montreal definition of GERD; symptoms without objective reflux) 1
• Esophageal dysmotility disorders (consider if connective tissue disease present) 1
• Eosinophilic esophagitis (especially if dysphagia predominates) 2

Extraesophageal Manifestations:

• Chronic cough, hoarseness, wheezing (established association with GERD but insufficient to prove causation) 1, 2
• Postprandial or reflux-associated dyspnea with aspiration risk 4

Cardiac Causes:

• Non-cardiac chest pain can mimic heartburn; ensure cardiac evaluation if presentation is atypical 1, 2

Initial Management Strategy

Pharmacologic Therapy:

• Start any commercially available PPI once daily, 30-60 minutes before breakfast for 4-8 weeks 1, 5
• Choice can be guided by insurance coverage and cost, as all PPIs are effective for initial therapy 1
• Provide patient education emphasizing PPI safety to address common concerns about long-term use 1
• Antacids may be used concomitantly with PPIs 5

Targeted Lifestyle Modifications (Grade B Evidence):

• Weight loss for overweight/obese patients has the strongest evidence for reducing GERD symptoms 1, 6
• Elevate head of bed by 6-8 inches for patients with nighttime symptoms or regurgitation when recumbent 1, 4, 6
• Avoid eating within 2-3 hours of bedtime to reduce nocturnal reflux burden 1, 4, 6
• Identify and avoid specific trigger foods (coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks) based on individual symptom patterns rather than blanket restrictions 1, 6
• Consider left lateral decubitus sleeping position to minimize reflux episodes 4

Patient Education:

• Explain that gastroesophageal reflux is a physiologic process controlled by protective factors (anti-reflux barrier, esophageal peristalsis, salivation, gastric motility) 1, 6
• Frame expectations regarding response to acid suppression and potential need for adjunctive strategies 1
• Introduce the brain-gut axis concept to encourage stress-reducing activities like mindfulness 1

Reassessment at 4-8 Weeks

If Adequate Response:

• Taper PPI to the lowest effective dose that maintains symptom control 1, 6
• Consider on-demand therapy for episodic symptoms 2

If Inadequate Response:

• Increase to twice-daily PPI dosing (e.g., omeprazole 40 mg twice daily) 1, 4
• Alternatively, switch to a more potent PPI (rabeprazole, esomeprazole) or extended-release formulation (dexlansoprazole) 1
• Add alginate-containing antacids for breakthrough symptoms, particularly postprandial, as they neutralize the acid pocket 4, 6
• Consider nighttime H2-receptor antagonist for nocturnal breakthrough, though tachyphylaxis is a concern 4
• Do not use metoclopramide due to unfavorable risk-benefit profile 6

Indications for Objective Testing

Perform Upper Endoscopy When:

• Alarm symptoms are present (dysphagia, weight loss, bleeding) 1, 2
• Inadequate response to optimized PPI therapy after 4-8 weeks 1, 6
• Patient requires long-term PPI without objective GERD confirmation (evaluate within 12 months) 1, 6
• Older age, male sex, obesity (risk factors for esophageal adenocarcinoma) 2

Perform Prolonged Wireless pH Monitoring (96-hour preferred) Off PPI When:

• Endoscopy shows no erosive esophagitis (Los Angeles B or greater) or long-segment Barrett's esophagus, yet symptoms persist 1
• Isolated extraesophageal symptoms with suspected reflux etiology (upfront testing preferred over empiric PPI trial) 1
• Need to establish appropriateness of long-term PPI therapy in unproven GERD 1
• GERD is confirmed by acid exposure time ≥6.0% on 2 or more days 4

Common Pitfalls to Avoid

• Do not assume nighttime symptoms predict treatment failure—nocturnal heartburn responds as well as daytime symptoms to PPI therapy in the vast majority of patients 6, 3
• Do not recommend broad lifestyle modifications indiscriminately—tailor recommendations to individual triggers and symptom patterns 1, 6
• Do not continue empiric PPI indefinitely without reassessment—evaluate response at 4-8 weeks and adjust accordingly 1, 6
• Do not perform empiric PPI trials for isolated extraesophageal symptoms—objective testing is preferred as mechanisms other than GERD frequently contribute 1
• Do not escalate H2-receptor antagonists—doubling the dose of H2RAs is not efficacious for persistent symptoms 7

Long-Term Management Considerations

For Confirmed GERD:

• Patients with confirmed GERD (erosive esophagitis or objective pH monitoring) may require indefinite long-term PPI therapy at the lowest effective dose 4, 2
• Routine re-evaluation of treatment should be performed with attempts at de-escalation 1
• Anti-reflux surgery (laparoscopic fundoplication) can be considered for patients failing maximal medical therapy, but only after comprehensive esophageal physiologic testing confirms GERD and adequate esophageal motility 4, 2

For Unproven GERD:

• If continuing PPI beyond 12 months without objective confirmation, perform endoscopy with prolonged pH monitoring off PPI (withhold for 2-4 weeks when possible) to establish appropriateness 1