Heartburn or regurgitation (adult)
Suspected GERD in an adult. Typical symptoms: heartburn and regurgitation.
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GERD Evaluation & Management (ACG 2022)
GERD Evaluation & Management (ACG 2022): Heartburn or regurgitation (adult) → Chest pain? Exclude a cardiac cause first → Typical GERD with no alarm fea...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Chest pain? Exclude a cardiac cause first
Heartburn-like chest pain can be acute coronary syndrome. Do not start a PPI trial until a cardiac cause is excluded.
- New, exertional or severe pain, sweating, breathlessness or radiation to arm or jaw: suspected ACS
- Suspected ACS: ECG within 10 min of first contact; in the community call 000 (ambulance)
- Chest pain without heartburn, cardiac cause excluded: EGD and/or pH testing, not an empiric PPI trial
03Decision Typical GERD with no alarm features?
Alarm features: dysphagia, painful swallowing, haematemesis or melaena, iron-deficiency anaemia, unexplained weight loss, recurrent vomiting, or 3 or more Barrett's risk factors
- If Yes
04Action No alarm features: typical GERD
Empiric PPI trial is appropriate. No test needed first.
- Epigastric pain or dyspepsia as the main symptom: use a dyspepsia pathway (H. pylori test and treat)
- Extra-oesophageal symptoms only (cough, hoarseness, asthma): look for other causes; reflux testing before a PPI
- Extra-oesophageal plus typical symptoms: PPI twice daily for 8 to 12 weeks is an option
- Older age raises cancer risk: lower the threshold for endoscopy
05Warning Before a PPI: pregnancy, drugs, liver
Check these before you choose or start a PPI. Cirrhosis or severe liver disease: no pantoprazole; use omeprazole 20 mg or esomeprazole max 20 mg daily.
- Pregnancy: lifestyle first, then antacid, alginate or sucralfate; give a PPI only if essential
- Clopidogrel: avoid omeprazole and esomeprazole. Cilostazol: omeprazole and esomeprazole contraindicated
- HIV medicines atazanavir, nelfinavir or rilpivirine (oral): do not give a PPI; ask the HIV prescriber
06Action PPI trial: once daily for 8 weeks
Adult. Alarm features: only after endoscopy. Take 30 to 60 min before breakfast, not at bedtime.
- Omeprazole 20 mg, esomeprazole 20 mg or pantoprazole 20 to 40 mg, oral, once daily
- Oesophagitis on EGD: healing dose, for example esomeprazole 40 mg once daily
- Start lifestyle measures at the same time
- Review at 8 weeks
- Warfarin: monitor INR after starting a PPI. High-dose methotrexate: consider stopping the PPI for the course
07Action Lifestyle measures (with the PPI)
Adjuncts to PPI therapy.
- Weight loss if overweight or obese
- No meals in the 2 to 3 hours before bed
- Stop smoking
- Avoid the patient's own trigger foods
- Raise the head of the bed for night-time symptoms
08Decision Symptoms resolved after 8 weeks?
Assess heartburn and regurgitation at 8 weeks.
- If Yes
09Action Resolved: try to stop the PPI
Do not stop if LA grade C or D oesophagitis or Barrett's: these need long-term PPI.
- LA grade C or D: long-term PPI or antireflux surgery. Barrett's: PPI at least once daily
- No oesophagitis and no Barrett's: stop the PPI, or use it on demand
- Symptoms return after stopping: EGD, ideally 2 to 4 weeks off PPI (antacids allowed)
- Needs ongoing PPI: lowest dose that controls symptoms
10Action If PPI still needed: long-term review
Use the lowest effective dose and review the need regularly.
- No routine calcium, vitamin D or bone density checks for PPI use alone
- Digoxin or diuretics: consider magnesium before and during long-term PPI
- Minor side effects: switch to another PPI
- Proven GERD and wants to stop medicine: consider antireflux surgery
If No11Action Not resolved: optimise the PPI, then EGD
Check adherence and timing first (30 to 60 min before a meal).
- Increase to twice daily (before breakfast and dinner), or switch to another PPI once
- Do not add baclofen without proof of GERD, or a prokinetic without proven gastroparesis
- Still symptomatic: EGD with oesophageal biopsies, ideally 2 to 4 weeks off PPI
- EoE or another cause found: treat that cause
- Refer to a gastroenterologist
12Action No cause on EGD: reflux testing
Gastroenterologist arranges ambulatory reflux monitoring (wireless or catheter-based).
- GERD not proven before: pH monitoring off PPI (stop PPI 7 days before)
- GERD proven (LA C or D, long-segment Barrett's, or abnormal pH study): impedance-pH on twice-daily PPI
- Testing and EGD unrevealing: high-resolution manometry
13Decision Reflux confirmed on testing?
Abnormal acid exposure or reflux linked to symptoms
- If Yes
14Action Reflux confirmed: consider antireflux surgery
Manometry first to exclude achalasia and absent contractility. Refer to an experienced surgeon.
- Most benefit: LA grade C or D, large hiatal hernia, persistent troublesome symptoms
- Regurgitation not controlled by PPI: fundoplication or magnetic sphincter augmentation
- Obesity: Roux-en-Y gastric bypass is an option
- Normal acid exposure but symptoms linked to reflux (reflux hypersensitivity): careful specialist selection
If No15Action Reflux not confirmed: stop the PPI
Normal acid exposure and no link between reflux and symptoms: stop the PPI unless there is another reason for it (for example Barrett's).
- Likely functional heartburn
- Gastroenterologist manages this
- Antireflux surgery is not indicated
If No16Warning Alarm features: bleeding or food stuck? Emergency now
Some alarm features need hospital care today, not an outpatient endoscopy referral.
- Haematemesis or melaena, now or in recent days: emergency department today; shock, fainting or ongoing bleeding: call 000
- Food stuck and cannot swallow saliva: emergency department now for emergency endoscopy
- No recent bleeding and swallowing saliva: refer for endoscopy as below
17Action Alarm features or Barrett's risk: endoscopy first
No recent bleeding: refer for upper endoscopy (EGD) before an empiric PPI trial. Suspected cancer: EGD within 2 weeks.
- Do FBC and ferritin
- Barrett's screen: chronic GERD plus 3 or more of male, age over 50, White, smoker, obesity, first-degree relative with Barrett's or oesophageal adenocarcinoma
- Dysphagia: oesophageal biopsies to exclude eosinophilic oesophagitis (EoE)
- Barium swallow alone does not diagnose GERD
18Action After endoscopy: act on the findings
Cancer or stricture: upper GI specialist. Iron-deficiency anaemia: also coeliac serology and colonoscopy, even if the EGD is normal.
- LA grade C or D oesophagitis or Barrett's: PPI healing course, then long-term PPI
- EoE: treat EoE (specialist); this pathway does not cover it
- Dysphagia with normal EGD and biopsies: gastroenterologist (for example manometry for achalasia)
- Normal or LA grade A or B: 8-week PPI trial
- Path rejoins step 05Shared downstream outcome
Guideline Source
ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease (Katz et al., 2022)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Not for infants, children or adolescents.
- Does not cover dyspepsia, eosinophilic oesophagitis or Barrett's surveillance; use their own guidance.
- Surgical and endoscopic antireflux options are summarised; the choice needs a specialist.
- Extra-oesophageal GERD (cough, laryngeal symptoms, asthma) is covered only briefly.
Contraindicated Populations
Children and adolescents under 18 yearsSuspected acute coronary syndrome (assess for ACS first)
Applicable Regions
USAUUKEU
AU: Australian PIs: symptomatic GORD dose (omeprazole 10 to 20 mg, esomeprazole 20 mg, pantoprazole 20 mg daily) for 4 weeks; investigate if not controlled. Suspected oesophagogastric cancer: EGD within 2 weeks (Cancer Council optimal care pathway).
UK: NICE CG184: full-dose PPI for 4 or 8 weeks for GORD; urgent cancer referral per NICE NG12.
US: ACG 2022 GERD guideline (8-week empiric PPI trial).
Version 2Next review: 2027-09-30
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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 the Diagnosis and Management of Gastroesophageal Reflux Disease (Katz et al., 2022).
What guideline is the GERD Evaluation & Management (ACG 2022) based on?
This algorithm is based on ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease (Katz et al., 2022) (DOI: 10.14309/ajg.0000000000001538).
What are the limitations of the GERD Evaluation & Management (ACG 2022)?
Known limitations include: Adults only. Not for infants, children or adolescents.; Does not cover dyspepsia, eosinophilic oesophagitis or Barrett's surveillance; use their own guidance.; Surgical and endoscopic antireflux options are summarised; the choice needs a specialist.; Extra-oesophageal GERD (cough, laryngeal symptoms, asthma) is covered only briefly.. Individual patient factors may require deviation from these recommendations.
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