GERD Symptoms
Heartburn, regurgitation ≥2x/week for ≥4 weeks
All Pathways
Family MedicineManagement
GERD Evaluation & Management (ACG 2022)
GERD Evaluation & Management (ACG 2022): GERD Symptoms → Alarm Features? → EGD Referral → PPI Trial (8 Weeks) → Lifestyle Modifications.
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Warning Alarm Features?
Require EGD evaluation
- Dysphagia or odynophagia
- Unintended weight loss
- GI bleeding or iron deficiency anemia
- Recurrent vomiting
- Age >60 with new-onset symptoms
- Family history upper GI cancer
03Action EGD Referral
Upper endoscopy indicated
- Perform before empiric PPI if alarm features
- Biopsy for Barrett's, eosinophilic esophagitis
- Rule out malignancy, stricture
- Can proceed with PPI after if no malignancy
04Action PPI Trial (8 Weeks)
Standard-dose PPI once daily
- Omeprazole 20mg, pantoprazole 40mg, esomeprazole 20-40mg
- Take 30-60 min before breakfast
- 8-week trial for adequate assessment
- Lifestyle modifications concurrent
05Action Lifestyle Modifications
Adjunctive measures
- Weight loss if overweight
- Elevate head of bed 6-8 inches
- Avoid late meals (≥3h before bed)
- Limit triggers: caffeine, alcohol, fatty foods
- Smoking cessation
06Decision Response to PPI?
Assess at 8 weeks
07Action PPI Responder
Step-down approach
- Taper to lowest effective dose
- Try every-other-day or on-demand
- Consider H2RA for maintenance
- If relapse, resume PPI at prior dose
- No need for long-term high-dose
08Action Maintenance Therapy
Long-term considerations
- Lowest effective PPI dose
- Annual attempt to step down
- No routine labs for PPI monitoring
- Ca/Vit D for osteoporosis risk
- Avoid unnecessary long-term use
09Action PPI Non-Responder
Further evaluation needed
- Optimize PPI: timing, compliance, twice daily
- EGD if not done (rule out EoE, other)
- Consider pH monitoring off PPI
- Assess for functional heartburn
- GI referral recommended
10Action Reflux Testing
Ambulatory pH monitoring
- Wireless pH (Bravo) or impedance-pH
- Off-PPI testing if diagnosis uncertain
- On-PPI testing if assessing refractory GERD
- Establishes reflux-symptom correlation
11Action Consider Anti-Reflux Surgery
Select patients
- Confirmed GERD responding to PPI but preferring no meds
- Large hiatal hernia with volume regurgitation
- Not for PPI non-responders (poor outcomes)
- Requires surgical expertise
12Action Typical GERD (No Alarms)
Empiric PPI trial appropriate
- Classic symptoms: heartburn, regurgitation
- Symptom response to PPI supports diagnosis
- No need for confirmatory testing initially
- Path rejoins step 04Shared downstream outcome
Guideline Source
ACG Clinical Guideline for GERD
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address Barrett's esophagus surveillance in detail
- H. pylori testing strategy simplified
- Surgical referral criteria abbreviated
- Does not address extra-esophageal GERD manifestations in depth
- PPI deprescribing approach simplified
Applicable Regions
USAUUKEU
AU: GESA guidelines align with ACG
UK: NICE GERD pathway with step-down approach
US: ACG 2022 guidelines
Version 1Next review: 2028-01-01
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the GERD Evaluation & Management (ACG 2022)?
The GERD Evaluation & Management (ACG 2022) is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline for GERD.
What guideline is the GERD Evaluation & Management (ACG 2022) based on?
This algorithm is based on ACG Clinical Guideline for GERD (DOI: 10.14309/ajg.0000000000001538).
What are the limitations of the GERD Evaluation & Management (ACG 2022)?
Known limitations include: Does not address Barrett's esophagus surveillance in detail; H. pylori testing strategy simplified; Surgical referral criteria abbreviated; Does not address extra-esophageal GERD manifestations in depth; PPI deprescribing approach simplified. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the GERD Evaluation & Management (ACG 2022) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free