When should a patient with Gastroesophageal Reflux Disease (GERD) be referred to a Gastrointestinal (GI) clinic?

When to Refer a GERD Patient to a GI Clinic

Refer GERD patients to gastroenterology when they have alarm symptoms, fail a 4-8 week trial of twice-daily PPI therapy, or require objective confirmation of GERD for long-term management decisions. 1

Immediate Referral Indications (Alarm Symptoms)

Refer urgently for upper endoscopy when patients present with any of the following alarm features:

• Dysphagia (difficulty swallowing) 1
• Gastrointestinal bleeding or anemia 1
• Unintentional weight loss 1
• Recurrent vomiting 1

These symptoms warrant immediate evaluation to exclude malignancy, strictures, or severe erosive disease that requires endoscopic assessment. 1

Referral After Failed PPI Therapy

Refer patients whose typical GERD symptoms (heartburn, regurgitation, non-cardiac chest pain) persist despite 4-8 weeks of twice-daily PPI therapy. 1 This represents true PPI failure and requires:

• Upper endoscopy to assess for erosive esophagitis (Los Angeles Grade B or higher), Barrett's esophagus, or alternative diagnoses 1
• If endoscopy is normal, prolonged wireless pH monitoring off PPI (96-hour preferred, with 7-day PPI washout) to confirm or exclude GERD 1

The AGA emphasizes that if PPI therapy continues beyond 12 months without proven GERD, referral for endoscopy with prolonged wireless reflux monitoring off PPI is indicated to establish appropriate use of long-term therapy. 1

Referral for Extraesophageal Symptoms

Refer patients with isolated extraesophageal symptoms (chronic cough, laryngitis, asthma, dental erosions) without typical heartburn for upfront objective testing rather than empiric PPI trials. 1 These patients require:

• Consideration of diagnostic testing before PPI initiation 1
• If one trial of PPI therapy (up to 12 weeks) fails, objective testing for pathologic reflux is indicated, as additional PPI trials are low yield 1
• Multidisciplinary evaluation may be necessary as these conditions are often multifactorial 1

Referral for Barrett's Esophagus Surveillance

Refer patients with:

• Severe erosive esophagitis after 2 months of PPI therapy to assess healing and rule out Barrett's esophagus 1
• Men over 50 years with chronic GERD symptoms (>5 years duration) plus additional risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use, central obesity) for Barrett's esophagus screening 1
• History of esophageal stricture with recurrent dysphagia 1

Referral for Surgical or Endoscopic Intervention Consideration

Refer patients with proven GERD (confirmed by endoscopy showing Los Angeles Grade B or higher erosive esophagitis, or pathologic acid exposure on pH monitoring) who:

• Desire alternatives to long-term PPI therapy 1
• Have persistent symptoms despite high-dose PPI therapy and documented ongoing reflux on pH-impedance monitoring 1
• Require candidacy assessment including exclusion of achalasia and evaluation of esophageal peristaltic function 1

Critical caveat: Lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into shared decision-making. 1

Practical Pitfalls to Avoid

• Do not refer for endoscopy in patients with typical GERD symptoms responding well to PPI therapy without alarm features. 1 This represents overuse without improving outcomes.
• Do not continue empiric PPI therapy indefinitely without objective confirmation of GERD. 1 Reevaluate appropriateness within 12 months of initiation.
• Do not assume symptom improvement on PPI confirms GERD in extraesophageal presentations. 1 Improvement may result from mechanisms other than acid suppression.
• Recognize that multimodality evaluation changes the diagnosis in 34.5% of PPI-refractory patients, 2 as overlap diagnoses (eosinophilic esophagitis, achalasia, gastroparesis, functional heartburn) are frequent and symptoms are non-specific.