What is the initial management for a patient presenting with heartburn, sour taste, or upper‑abdominal discomfort?

Initial Management of Heartburn, Sour Taste, and Upper Abdominal Discomfort

Start with a 4-8 week trial of a proton pump inhibitor (PPI) taken once daily, 30-60 minutes before breakfast, in patients without alarm symptoms. 1

First-Line Treatment Approach

• Initiate omeprazole 20 mg once daily or any commercially available PPI (lansoprazole, pantoprazole, rabeprazole, esomeprazole, dexlansoprazole) taken 30-60 minutes before a meal for 4-8 weeks. 1, 2
• PPIs are significantly more effective than H2-receptor antagonists (H2RAs) for symptom relief and healing of erosive disease, making them the preferred first-line agents. 3, 4
• Proper timing is critical: taking PPIs with food or at bedtime significantly reduces efficacy. 3

Screen for Alarm Symptoms First

Before starting empiric PPI therapy, assess for alarm features that warrant immediate endoscopy rather than empiric treatment: 1, 3

• Dysphagia (difficulty swallowing)
• Evidence of gastrointestinal bleeding
• Anemia
• Unintentional weight loss (>5% of body weight)
• Recurrent vomiting

If any alarm symptoms are present, proceed directly to esophagogastroduodenoscopy (EGD) rather than empiric therapy. 1, 5

Concurrent Lifestyle and Dietary Modifications

Provide standardized education on the following measures to support pharmacotherapy: 1

• Weight loss if overweight or obese (obesity is a significant modifiable risk factor). 3, 6
• Avoid trigger foods: fatty/fried foods, spicy foods, citrus juices, tomatoes, chocolate, coffee, carbonated beverages, and alcohol. 3, 6
• Elevate the head of the bed by 6-8 inches if nighttime symptoms are present. 3
• Eat smaller, more frequent meals rather than large volume meals. 6
• Avoid eating within 2-3 hours of bedtime. 6
• Smoking cessation (smoking is a modifiable risk factor for GERD). 6

Antacids may be used concomitantly with PPIs for breakthrough symptoms. 2

Treatment Duration and Response Assessment

• Reassess symptoms after 4-8 weeks of once-daily PPI therapy. 1, 2
• If symptoms resolve, taper to the lowest effective dose for maintenance. 1
• Most patients with uncomplicated GERD will respond within this timeframe. 2, 4

Management of Inadequate Response

If symptoms persist after 4-8 weeks of once-daily PPI: 1

• Increase to twice-daily PPI dosing (before breakfast and before dinner) for an additional 4-8 weeks. 1, 3
• Confirm the patient is taking the medication correctly (30-60 minutes before meals, not with food). 3
• Consider switching to a different PPI if no response to dose escalation. 1

When to Pursue Objective Testing

If symptoms persist despite twice-daily PPI therapy for 8 weeks total, proceed with endoscopy rather than continuing empiric therapy indefinitely. 1

The American Gastroenterological Association recommends: 1

• EGD to evaluate for erosive esophagitis (Los Angeles classification), Barrett's esophagus, peptic ulcer disease, or alternative diagnoses
• If endoscopy is negative (no erosive disease), perform prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm or rule out GERD
• Continuing long-term PPI without objective confirmation of GERD diagnosis is inappropriate

Special Consideration for Extraesophageal Symptoms

If the patient presents with isolated extraesophageal symptoms (chronic cough, hoarseness, throat clearing) WITHOUT typical heartburn or regurgitation, perform upfront objective reflux testing rather than an empiric PPI trial. 1

This is because 50-60% of patients with extraesophageal symptoms will not have GERD and will not respond to anti-reflux therapies. 1 The diagnostic performance of empiric PPI trials is substantially lower for extraesophageal symptoms compared to typical reflux symptoms. 1

Common Pitfalls to Avoid

• Do not continue empiric PPI therapy indefinitely without confirming the diagnosis if the patient fails to respond adequately. 1
• Do not assume GERD is ruled out if initial therapy fails; the dose or duration may have been inadequate, or non-acid reflux may be present. 1
• Do not order extensive testing before trying empiric therapy in patients with typical symptoms and no alarm features. 1
• Do not take PPIs at bedtime or with meals—this significantly reduces acid suppression efficacy. 3
• Do not use H2RAs as first-line therapy when PPIs are available and not contraindicated, as they are less effective. 3, 4

Long-Term Management

For patients who respond to initial therapy: 1

• Attempt to taper to the lowest effective dose after 8-12 weeks
• On-demand or intermittent therapy may be appropriate for mild, intermittent symptoms
• If continuous therapy is required beyond 12 months, objective testing should be considered to confirm GERD diagnosis and appropriateness of long-term PPI use

PPIs are safe for long-term use when appropriately indicated, and clinicians should emphasize this safety to patients. 1, 7