What management approach should be taken for a 55-year-old woman with a history of leisure activities, no dysphagia, occasional non-cardiac chest pain, and mild reflux, who is already on a Proton Pump Inhibitor (PPI)?

Management of Non-Cardiac Chest Pain in a Patient Already on PPI

Since this patient has occasional non-cardiac chest pain with mild reflux and is already on a PPI, you should first optimize her current PPI therapy by ensuring proper timing (30-60 minutes before meals) and consider escalating to twice-daily dosing if symptoms persist, but within 12 months you must perform objective testing with endoscopy and prolonged wireless pH monitoring off PPI to confirm whether true GERD exists before continuing long-term acid suppression. 1, 2

Immediate Management Steps

Optimize Current PPI Therapy

• Verify proper PPI administration: Ensure she takes it 30-60 minutes before meals, as improper timing is a common cause of apparent treatment failure 2, 3
• If symptoms persist on once-daily dosing: Escalate to twice-daily PPI therapy for 4 weeks, which is the recommended approach for non-cardiac chest pain after cardiac etiology has been excluded 1
• Consider switching PPIs: If inadequate response occurs, switch to a different PPI or more potent acid suppressive agent once daily before escalating to twice-daily dosing 1

Critical Diagnostic Timeline

• Within 12 months of PPI initiation: You must evaluate the appropriateness of continuing PPI therapy and offer objective testing to establish whether long-term PPI use is justified 1
• If symptoms do not respond adequately to optimized PPI: Proceed immediately to diagnostic evaluation rather than waiting the full 12 months 1

Diagnostic Evaluation Required

Step 1: Upper Endoscopy

• Perform endoscopy to evaluate for: Erosive esophagitis (Los Angeles classification), Barrett's esophagus (Prague classification with biopsy), hiatal hernia, and alternative diagnoses 1
• Complete endoscopic assessment includes: Inspection of diaphragmatic hiatus (Hill grade of flap valve) and axial hiatus hernia length 1

Step 2: Prolonged Wireless pH Monitoring Off PPI

• If endoscopy shows no erosive disease (Los Angeles B or greater) or long-segment Barrett's esophagus: Perform prolonged wireless pH monitoring off medication to confirm or rule out GERD 1, 2
• Discontinue PPI for 2-4 weeks before testing to allow accurate assessment 2
• Preferred test: 96-hour wireless pH monitoring (Bravo capsule) provides superior diagnostic accuracy compared to 24-hour catheter-based monitoring 2

Step 3: Esophageal Manometry

• Perform manometry to exclude achalasia, distal esophageal spasm, or other motility disorders that can masquerade as GERD 1, 3
• This is particularly important before considering any surgical intervention 1

Interpretation and Next Steps

If Acid Exposure Time (AET) >4% on ≥1 Day

• Confirms true GERD: Continue optimized PPI therapy and taper to lowest effective dose once symptoms controlled 1, 2
• Consider adjunctive therapy personalized to GERD phenotype (not empirically) if symptoms persist on twice-daily PPI 2

If AET <4% on All Days

• Patient does not have GERD: Likely has functional heartburn or reflux hypersensitivity 2
• Initiate neuromodulation or behavioral interventions and taper PPI off as tolerated 1
• Consider citalopram 20 mg once daily for functional chest pain, which has shown 67% complete symptom resolution in patients with negative symptom index 4

If Positive Symptom Association Despite Normal Acid Exposure

• Consider combined therapy: Citalopram 20 mg plus PPI once daily has shown 72% complete symptom resolution in patients with positive symptom index but normal acid exposure 4

Critical Pitfalls to Avoid

• Do not continue long-term PPI indefinitely without establishing a definitive diagnosis when the patient has only mild reflux and occasional symptoms 1, 2
• Do not empirically add H2-receptor antagonists or other adjunctive agents without objective confirmation of GERD phenotype 2
• Do not perform pH monitoring while on PPI as the initial diagnostic test in this scenario—testing should be done off PPI to establish the diagnosis 2
• Do not assume all chest pain is GERD-related even when mild reflux is present; functional disorders are common mimics 1, 3
• Beware of misdiagnosis: Eosinophilic esophagitis, achalasia, and functional heartburn can all present similarly and require different management 1, 3

Patient Education and Lifestyle Modifications

• Provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, and relaxation strategies 1
• Emphasize PPI safety to address patient concerns about long-term use, while also explaining the importance of confirming the diagnosis 1
• Engage in shared decision-making regarding the diagnostic workup and long-term management plan 1