In a 50‑year‑old man with six months of refractory gastro‑oesophageal reflux disease symptoms, what is the most appropriate next step: advise lifestyle modification, increase the proton‑pump inhibitor dose, refer for upper endoscopy, or observe?

Refer this patient for upper endoscopy

This 50-year-old male with 6 months of GERD symptoms refractory to treatment meets clear criteria for referral to a gastroenterologist for upper endoscopy. The American College of Physicians explicitly states that if 4 to 8 weeks of twice-daily PPI therapy is unsuccessful, further investigation with endoscopy is recommended 1.

Why Endoscopy is Indicated Now

Duration and Treatment Failure

• Six months of persistent symptoms despite treatment represents therapeutic failure that mandates endoscopic evaluation 1, 2.
• The patient has already had "no improvement" on antacid therapy, which suggests either inadequate acid suppression or an alternative diagnosis 1.
• Continuing empirical therapy beyond 4-8 weeks of optimized treatment without objective testing is explicitly discouraged 3.

Age and Risk Factor Profile

• At 50 years old, this male patient enters the high-risk category for Barrett's esophagus and esophageal adenocarcinoma 1.
• Men over 50 with chronic GERD symptoms (>5 years not required when refractory) should undergo endoscopy to detect esophageal adenocarcinoma and Barrett's esophagus 1.
• The yield of endoscopy is highest in this demographic, making it both clinically appropriate and cost-effective 1.

Diagnostic Yield

• Greater than 50% of patients undergoing endoscopy for refractory GERD have clinically actionable findings including erosive esophagitis, Barrett's esophagus, strictures, or malignancy 1, 2.
• Endoscopy can identify severe erosive esophagitis (grade B or worse), which has substantial rates of incomplete healing with medical therapy and may harbor Barrett's esophagus 1.

Why Other Options Are Inadequate

Option A (Lifestyle Modification Alone)

• Lifestyle modifications should have been implemented at initial presentation, not after 6 months of treatment failure 1.
• Delaying endoscopy to retry lifestyle changes risks missing serious pathology including malignancy in this high-risk patient 2.

Option B (Increase Antacid Dose)

• The term "antacid" is ambiguous—if this means H2-receptor antagonists, they are inferior to PPIs and inappropriate for refractory disease 1.
• If already on a PPI, the dose should have been escalated to twice-daily dosing weeks ago 1.
• Even if not yet on twice-daily PPI therapy, 6 months of any treatment without improvement mandates investigation, not further empirical escalation 2, 3.

Option D (Observe)

• Observation is contraindicated in a 50-year-old male with 6-month refractory GERD given the risk of Barrett's esophagus and adenocarcinoma 1.
• The patient is actively requesting specialist referral, indicating symptom burden affecting quality of life 1.
• Continued observation without investigation exposes the patient to ongoing symptoms and potential progression of undiagnosed pathology 2.

Proper Management Algorithm

Step 1: Confirm Treatment Adequacy

• Verify the patient has received twice-daily PPI therapy for at least 4-8 weeks taken 30-60 minutes before meals 1.
• If not, optimize to twice-daily dosing immediately while arranging endoscopy 1.

Step 2: Immediate Referral for Endoscopy

• Refer directly to gastroenterology for upper endoscopy (open-access endoscopy is appropriate) 1.
• Do not delay referral to retry empirical therapies 2, 3.

Step 3: Screen for Alarm Symptoms

• Specifically ask about dysphagia, bleeding, anemia, weight loss, or recurrent vomiting—any of these mandate urgent endoscopy 1, 2.
• Even without alarm symptoms, refractory disease in this demographic warrants endoscopy 1.

Critical Pitfalls to Avoid

• Do not continue empirical PPI therapy beyond 4-8 weeks of twice-daily dosing without endoscopy in treatment-refractory patients 3.
• Do not assume all heartburn is benign GERD—up to 40% of patients on standard PPI therapy have persistent symptoms from alternative diagnoses 4, 5.
• Do not use age alone to defer endoscopy—the combination of male sex, age ≥50, and chronic refractory symptoms creates sufficient risk to justify investigation 1.
• Do not substitute barium studies for endoscopy—upper GI series cannot assess for Barrett's esophagus, dysplasia, or mucosal inflammation adequately 3.

The correct answer is C: Refer the patient to specialist for endoscopy.