What is the recommended workup for a patient presenting with symptoms of Gastroesophageal Reflux Disease (GERD)?

GERD Workup: A Stepwise Diagnostic Approach

For patients presenting with typical GERD symptoms (heartburn, regurgitation) without alarm features, begin with a 4-8 week empiric trial of single-dose PPI therapy without initial endoscopy—this is both safe and appropriate as first-line management. 1

Initial Clinical Assessment

Identify alarm symptoms that mandate immediate endoscopy:

• Dysphagia (difficulty swallowing)
• Unintentional weight loss
• Gastrointestinal bleeding or anemia
• Persistent vomiting
• Recurrent vomiting
• Palpable abdominal mass 1, 2

Document typical GERD symptoms:

• Heartburn occurring after meals and when lying down 2
• Regurgitation of acidic or bitter material 2
• Non-cardiac chest pain 1
• Symptoms worsening with bending over or lying supine 2

Screen for extraesophageal manifestations:

• Chronic cough
• Laryngeal hoarseness or dysphonia
• Throat clearing
• Dental erosions 2

Empiric Treatment Phase (No Alarm Symptoms)

Start single-dose PPI therapy for 4-8 weeks (any PPI is acceptable: omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole, or dexlansoprazole). 1 Dose 30-60 minutes before a meal for optimal efficacy. 1

Provide patient education on:

• GERD pathophysiology and mechanisms 1
• Weight management (recommend weight loss if BMI ≥25) 3
• Lifestyle modifications: avoid lying down 2-3 hours after meals, elevate head of bed 6-8 inches for nocturnal symptoms 3
• Dietary triggers: identify individual trigger foods rather than blanket restrictions 3
• PPI safety to address patient concerns 1

Response Assessment at 4-8 Weeks

If symptoms resolve: Taper PPI to the lowest effective dose or convert to on-demand therapy. 1 No endoscopy needed if symptoms remain controlled. 1

If partial or no response: Escalate to twice-daily PPI dosing (before breakfast and dinner) or switch to a more potent acid suppressive agent. 1 Reassess after another 4-8 weeks. 1

Indications for Upper Endoscopy

Proceed directly to endoscopy in these scenarios:

• Presence of any alarm symptoms 1, 2
• Inadequate response after 4-8 weeks of twice-daily PPI therapy 1
• Isolated extraesophageal symptoms (perform upfront testing rather than empiric PPI trial) 1
• Planning long-term PPI therapy beyond 12 months in patients with unproven GERD 1, 2
• Patients meeting Barrett's esophagus screening criteria: men >50 years with chronic GERD symptoms (>5 years) 1
• History of severe erosive esophagitis (Los Angeles grade B or worse) requiring follow-up endoscopy after 8 weeks of PPI therapy 1

Complete endoscopic evaluation must document:

• Erosive esophagitis graded by Los Angeles classification (A-D) 1
• Diaphragmatic hiatus integrity (Hill grade of flap valve) 1
• Axial hiatus hernia length 1
• Barrett's esophagus presence/absence with Prague classification and biopsy if present 1

Prolonged pH Monitoring

Perform 96-hour wireless pH monitoring off PPI therapy when:

• Endoscopy shows no erosive disease (less than Los Angeles B) AND no long-segment Barrett's esophagus (≥3cm) 1
• Need to confirm GERD diagnosis before committing to long-term therapy 1
• Evaluating PPI non-responders to phenotype reflux pattern 1

Consider 24-hour pH-impedance monitoring on PPI for:

• Symptomatic patients with proven GERD who have persistent symptoms despite therapy 1
• Determining mechanism of PPI-refractory symptoms (reflux hypersensitivity, functional heartburn, rumination) 1

Special Populations and Scenarios

Extraesophageal symptoms (chronic cough, laryngitis, asthma):

• Perform upfront objective reflux testing off medication rather than empiric PPI trial 1
• If empiric therapy chosen, use twice-daily PPI for minimum 8-12 weeks 1, 3
• Response rates are significantly lower than typical GERD symptoms 3
• Consider adding prokinetic therapy if PPI alone ineffective 1, 3

Barrett's esophagus screening candidates:

• Men >50 years with chronic GERD (>5 years of symptoms or >5 years of medical therapy) 1
• Women and patients <50 years: routine screening not recommended due to low cancer incidence 1
• If initial screening negative for Barrett's, no repeat endoscopy needed even with continued symptoms 1

Severe erosive esophagitis (Los Angeles grade B or worse):

• Repeat endoscopy after 8 weeks of PPI therapy to ensure healing and rule out Barrett's esophagus 1
• Incomplete healing rate is substantial (44%) with medical therapy alone 1

Common Pitfalls to Avoid

Do not perform serial endoscopies in patients with:

• GERD and no Barrett's esophagus on initial exam 1
• Well-controlled symptoms on medical therapy 1
• History of stricture who remain asymptomatic 1

Do not assume GERD diagnosis based solely on:

• Symptom improvement with PPI therapy 2
• Typical reflux symptoms in populations with high H. pylori prevalence 2

Do not continue long-term PPI without:

• Objective confirmation via endoscopy or pH monitoring when planning treatment beyond 12 months 1, 2
• Reassessing appropriateness and dosing within 12 months of initiation 1

Do not use endoscopy for:

• Initial evaluation of uncomplicated typical GERD symptoms 1
• Barrett's surveillance at intervals shorter than 3-5 years in patients without dysplasia 1