GERD Evaluation & Management (ACG 2022)

Algorithm Steps

1. ▶

   Start

   GERD Symptoms

   Heartburn, regurgitation ≥2x/week for ≥4 weeks

   1. ⚠

      Warning

      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
      1. ●

         Action

         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
         1. ●

            Action

            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
            1. ●

               Action

               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
            2. ◆

               Decision

               Response to PPI?

               Assess at 8 weeks

               1. ●

                  Action

                  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
                  1. ●

                     Action

                     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
               2. ●

                  Action

                  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
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
      2. ●

         Action

         Typical GERD (No Alarms)

         Empiric PPI trial appropriate

         • Classic symptoms: heartburn, regurgitation
         • Symptom response to PPI supports diagnosis
         • No need for confirmatory testing initially