How should a patient presenting to the emergency department with symptoms suggestive of gastro‑oesophageal reflux disease and no red‑flag features be managed initially?

GERD Treatment in the Emergency Department

For patients presenting to the ED with typical GERD symptoms (heartburn, regurgitation) and no alarm features, initiate empirical treatment with a proton pump inhibitor (PPI) 20–40 mg once daily for 4–8 weeks and discharge with outpatient follow-up. 1, 2

Immediate Assessment: Rule Out Red Flags

Before diagnosing GERD, exclude alarm symptoms that mandate urgent endoscopy or alternative workup 1, 3:

• Dysphagia (difficulty swallowing) – requires endoscopy with ≥5 esophageal biopsies to exclude eosinophilic esophagitis 1, 3
• Odynophagia (painful swallowing) – warrants immediate endoscopy 1
• Gastrointestinal bleeding or anemia – requires urgent evaluation 3
• Unexplained weight loss (>5% body weight) – mandates endoscopy 1, 3
• Recurrent vomiting – needs specialist assessment 3
• Epigastric mass on examination – requires imaging and endoscopy 1
• Food bolus obstruction – requires same-day or emergency endoscopy 3

If any alarm feature is present, do not initiate empirical PPI therapy; arrange urgent gastroenterology consultation or endoscopy. 1

Chest Pain Presentations: Cardiac Evaluation First

When chest pain is the presenting symptom, cardiac ischemia must be thoroughly excluded before attributing symptoms to GERD, because ischemic heart disease carries substantially greater morbidity and mortality. 4

• Complete cardiac workup (ECG, troponin, stress testing as indicated) before considering GERD 4
• Only after cardiac etiology is ruled out, initiate twice-daily PPI therapy (e.g., omeprazole 20 mg twice daily) for 4 weeks as an empirical trial for suspected reflux chest pain syndrome (Grade A recommendation) 4
• If chest pain persists after 4 weeks of twice-daily PPI, refer for esophageal manometry and pH/impedance monitoring to exclude motility disorders 4

Empirical PPI Therapy for Typical GERD Symptoms

For patients with heartburn and/or regurgitation without alarm features, prescribe once-daily PPI therapy 5, 1, 2:

• Omeprazole 20 mg once daily (or equivalent: lansoprazole 30 mg, pantoprazole 40 mg) 5, 2
• Administer 30–60 minutes before breakfast (not at bedtime or with food, as this markedly reduces efficacy) 5
• Treatment duration: 4–8 weeks for initial symptom control 5, 2, 6
• Antacids may be used concomitantly for breakthrough symptoms 2

Common pitfall: Taking PPIs at bedtime or with meals impairs acid suppression; emphasize pre-meal timing at discharge 5.

Extraesophageal Symptoms (Cough, Laryngitis, Asthma)

Do not initiate empirical PPI therapy for isolated extraesophageal symptoms (chronic cough, laryngitis, asthma) without concurrent typical GERD symptoms (Grade D recommendation – advise against) 4, 1:

• Isolated throat or respiratory symptoms are multifactorial and rarely caused by GERD alone 4
• If typical heartburn or regurgitation is also present, empirical twice-daily PPI therapy for 2–3 months may be considered (Grade B recommendation) 4, 5
• Extraesophageal symptoms require 2–3 months of continuous therapy before improvement, significantly longer than typical GERD 5

Discharge Instructions and Follow-Up

Provide clear discharge instructions 5, 2:

• Take PPI 30–60 minutes before breakfast daily 5
• Continue lifestyle modifications: elevate head of bed, avoid meals 3 hours before bedtime, weight loss if overweight, tobacco and alcohol cessation 3
• If symptoms persist after 4–8 weeks of once-daily PPI, escalate to twice-daily dosing (e.g., omeprazole 20 mg before breakfast and dinner) for an additional 4–8 weeks 5, 1
• If symptoms persist after 4–8 weeks of twice-daily PPI, refer to gastroenterology for upper endoscopy, esophageal manometry, and pH/impedance monitoring 1, 3

High-Risk Patients Requiring Outpatient Gastroenterology Referral

Arrange outpatient gastroenterology follow-up (not urgent) for 3:

• Men >50 years with chronic GERD >5 years plus additional risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use, central obesity) – for Barrett's esophagus screening 3
• Severe erosive esophagitis after 2 months of PPI therapy – to assess healing and rule out Barrett's esophagus 3
• History of esophageal stricture with recurrent dysphagia 3
• Known Barrett's esophagus requiring surveillance 3

What NOT to Do in the ED

• Do not perform endoscopy for uncomplicated GERD symptoms without alarm features 1, 3
• Do not order reflux monitoring (pH or pH/impedance testing) in the ED; this is reserved for PPI-refractory cases in the outpatient setting 4, 1
• Do not prescribe H2-receptor antagonists (e.g., famotidine) in combination with PPIs; this combination is not evidence-based for routine GERD management 5
• Do not prescribe prokinetics (e.g., metoclopramide) for GERD; they have not been proven effective and carry side-effect risks 7

Expected Outcomes

• Most patients (70–80%) achieve symptom control with once-daily PPI therapy within 4–8 weeks 6, 7
• Relapse occurs in approximately 70% of patients within 6 months after PPI discontinuation, so maintenance therapy or on-demand dosing is often required 6
• Twice-daily PPI achieves normalization of esophageal acid exposure in 93–99% of patients, though this does not always correlate with symptom relief in extraesophageal manifestations 5