One-liner#

Evaluate dyspepsia and GERD symptoms to identify patients needing endoscopy (alarm features, refractory symptoms) while efficiently managing the majority with empiric PPI therapy and H. pylori test-and-treat.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• GI bleeding: hematemesis, melena, hematochezia with hemodynamic instability
• Severe abdominal pain with peritoneal signs (perforation)
• Complete dysphagia (unable to swallow saliva)
• Severe dehydration from persistent vomiting

Alarm features (warrant EGD, not necessarily ED)#

• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Unintentional weight loss (>5% in 6 months)
• GI bleeding (hematemesis, melena, iron deficiency anemia)
• Persistent vomiting
• Palpable abdominal mass or lymphadenopathy
• Family history of upper GI malignancy
• Age >60 with new-onset dyspepsia (lower threshold for EGD)

Key history#

Distinguish dyspepsia from GERD:

Dyspepsia subtypes (Rome IV):

• Postprandial distress syndrome: early satiety, postprandial fullness
• Epigastric pain syndrome: epigastric burning or pain

GERD symptoms:

• Typical: heartburn, regurgitation
• Atypical: chronic cough, hoarseness, throat clearing, globus sensation, dental erosions
• Extraesophageal: asthma exacerbation, laryngitis

Key questions:

• Duration: acute vs chronic
• Frequency: daily, weekly, occasional
• Severity: impact on quality of life, sleep disruption
• Triggers: specific foods, alcohol, caffeine, lying down, large meals
• Relief: antacids, PPIs, food, position changes
• Prior treatment: what has been tried and response

Risk factors for organic disease:

• NSAID use (peptic ulcer)
• H. pylori infection
• Smoking
• Alcohol
• Family history of gastric cancer
• Prior peptic ulcer disease

Medication review:

• NSAIDs, aspirin (ulcer, gastritis)
• Bisphosphonates (esophagitis—take correctly?)
• Potassium, iron, tetracyclines (pill esophagitis)
• Calcium channel blockers, nitrates (lower LES pressure)

Focused exam#

• Vitals: usually normal; weight trend
• General: nutritional status, pallor (anemia)
• Abdominal: epigastric tenderness, masses, organomegaly
• Lymph nodes: supraclavicular (Virchow’s node—gastric cancer)
• Skin: pallor (anemia from bleeding)
• Oral: dental erosions (chronic GERD/vomiting)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Empiric treatment vs testing:

H. pylori testing:

• Urea breath test: preferred; high sensitivity/specificity
• Stool antigen: alternative; good accuracy
• Serology: NOT recommended (remains positive after treatment; can’t confirm eradication)

Important: Stop PPI for 2 weeks and antibiotics for 4 weeks before H. pylori testing (false negatives).

When to order EGD:

• Alarm features (dysphagia, weight loss, bleeding, anemia, vomiting)
• Age ≥60 with new-onset dyspepsia
• Refractory symptoms despite 8 weeks of PPI
• Need to confirm H. pylori eradication in ulcer disease
• Surveillance (Barrett’s esophagus, prior gastric ulcer)

When NOT to order EGD:

• Young patient (<60) with typical GERD, no alarm features, responding to PPI
• Functional dyspepsia meeting Rome IV criteria with negative H. pylori

Additional workup if indicated:

• CBC: anemia (bleeding)
• Iron studies: if anemia present
• LFTs: if biliary disease suspected
• Lipase: if pancreatitis suspected

Initial management#

GERD (no alarm features):

1. Lifestyle modifications (see below)
2. PPI trial x 4–8 weeks
3. If responds: attempt step-down to H2RA or PRN PPI
4. If refractory: EGD

Dyspepsia (no alarm features):

1. H. pylori test-and-treat (if positive, treat; if negative, PPI trial)
2. OR empiric PPI trial x 4–8 weeks
3. If refractory: EGD

Lifestyle modifications (all patients):

• Weight loss if overweight (most effective intervention for GERD)
• Elevate head of bed 6–8 inches (blocks under bedposts, not just pillows)
• Avoid eating 2–3 hours before bedtime
• Avoid trigger foods: fatty foods, chocolate, caffeine, alcohol, mint, citrus, tomatoes
• Smoking cessation
• Avoid tight-fitting clothing
• Small, frequent meals

Management by diagnosis#

GERD (Gastroesophageal reflux disease)#

Education:

• Stomach acid flowing back into esophagus
• Lifestyle changes are as important as medication
• Most patients can eventually step down from daily PPI
• Long-term untreated GERD can lead to Barrett’s esophagus (precancerous)

Treatment:

Step 1: Lifestyle modifications (see above)

Step 2: Acid suppression

PPI prescribing pearls:

• Take 30–60 minutes before first meal of the day (maximizes efficacy)
• Once-daily dosing sufficient for most; BID for severe/refractory
• All PPIs similarly effective; choose based on cost and interactions
• If one PPI fails, can try another (some patients respond differently)
• Drug interactions: Omeprazole/esomeprazole may reduce clopidogrel efficacy (CYP2C19); use pantoprazole if on clopidogrel

Step 3: If refractory to 8 weeks PPI:

• Confirm adherence and proper timing
• EGD to evaluate for complications, alternative diagnoses
• Consider pH monitoring (off PPI) to confirm diagnosis
• GI referral for refractory cases

Long-term PPI considerations:

• Attempt step-down after 4–8 weeks: reduce to lowest effective dose, switch to H2RA, or PRN use
• Long-term risks (generally small): C. diff, pneumonia, hip fracture, hypomagnesemia, B12 deficiency
• Benefits outweigh risks for patients with documented GERD, Barrett’s, or erosive esophagitis
• Avoid indefinite PPI without clear indication

Follow-up: 4–8 weeks; if improved, attempt step-down. If refractory, EGD.

Functional dyspepsia#

Education:

• Stomach discomfort without ulcer or structural cause
• Related to how stomach processes food and signals to brain
• Chronic condition; goal is symptom management
• Not dangerous; does not lead to cancer

Treatment:

Step 1: H. pylori test-and-treat

• If positive: eradication may improve symptoms in ~10% (NNT ~14)
• If negative: proceed to PPI trial

Step 2: PPI trial x 4–8 weeks

• Effective in ~30–40% of functional dyspepsia

Step 3: If PPI fails—neuromodulators

Step 4: Prokinetics (if delayed gastric emptying suspected)

Follow-up: 4–8 weeks after each intervention; GI referral if refractory to multiple treatments.

H. pylori infection#

Education:

• Bacterial infection of the stomach lining
• Associated with ulcers and (rarely) gastric cancer
• Curable with antibiotics + acid suppression
• Confirm eradication after treatment (for ulcer disease)

Treatment:

First-line regimens (14 days preferred):

If penicillin allergy:

• Bismuth quadruple therapy (no amoxicillin)
• OR: PPI + clarithromycin + metronidazole x 14 days

Confirm eradication:

• Urea breath test or stool antigen ≥4 weeks after completing treatment
• Stop PPI 2 weeks before testing
• Required for: peptic ulcer disease, gastric MALT lymphoma, after gastric cancer resection
• Optional but recommended for: all treated patients

If first-line fails:

• Avoid regimen with same antibiotics
• Bismuth quadruple if not used initially
• Levofloxacin-based regimen: PPI BID + levofloxacin 500 mg daily + amoxicillin 1 g BID x 14 days
• GI referral for culture and sensitivity if multiple failures

Follow-up: Confirm eradication 4+ weeks after treatment completion.

Peptic ulcer disease#

Education:

• Sore in the lining of stomach or duodenum
• Usually caused by H. pylori or NSAIDs
• Heals with acid suppression; must treat underlying cause
• Complications: bleeding, perforation, obstruction

Treatment:

Acute management:

• Stop NSAIDs
• PPI x 4–8 weeks (8 weeks for gastric ulcer)
• Test and treat H. pylori

H. pylori eradication: See above

NSAID-induced ulcer:

• Stop NSAID if possible
• If NSAID must continue: PPI co-therapy indefinitely
• Consider COX-2 selective NSAID (celecoxib) + PPI if high GI risk but need NSAID

Follow-up:

• Duodenal ulcer: confirm H. pylori eradication; repeat EGD not routinely needed
• Gastric ulcer: repeat EGD in 8–12 weeks to confirm healing and rule out malignancy
• If H. pylori negative and no NSAID use: consider Zollinger-Ellison syndrome (check fasting gastrin)

Barrett’s esophagus#

Education:

• Precancerous change in esophageal lining from chronic acid exposure
• Requires ongoing PPI therapy and surveillance endoscopy
• Most patients with Barrett’s do NOT develop cancer, but monitoring is important

PCP role:

• Continue PPI therapy (indefinitely)
• Ensure GI follow-up for surveillance EGD
• Lifestyle modifications for GERD

Surveillance intervals (GI manages):

• No dysplasia: EGD every 3–5 years
• Low-grade dysplasia: EGD every 6–12 months or ablation
• High-grade dysplasia: ablation or resection

Follow-up: GI manages surveillance; PCP continues PPI and monitors for symptoms.

Follow-up#

• GERD responding to PPI: 4–8 weeks; attempt step-down
• GERD refractory to PPI: EGD; GI referral
• Functional dyspepsia: 4–8 weeks after each intervention
• H. pylori: Confirm eradication 4+ weeks after treatment
• Peptic ulcer: Confirm H. pylori eradication; gastric ulcers need repeat EGD

When to refer to GI:

• Alarm features requiring EGD
• Refractory symptoms despite 8 weeks PPI
• Barrett’s esophagus (for surveillance)
• Complicated peptic ulcer disease
• Failed H. pylori eradication (multiple regimens)
• Consideration for anti-reflux surgery

Patient instructions#

For GERD:

• Take your PPI 30–60 minutes before breakfast for best effect.
• Avoid eating 2–3 hours before bedtime.
• Raise the head of your bed 6–8 inches (put blocks under the bedposts).
• Avoid foods that trigger your symptoms: fatty foods, chocolate, caffeine, alcohol, mint, citrus.
• Lose weight if overweight—this is the most effective lifestyle change.
• Don’t lie down right after eating.
• Call the office if you have trouble swallowing, vomiting blood, black stools, or unintentional weight loss.

For H. pylori treatment:

• Take all medications exactly as prescribed for the full course (usually 14 days).
• You may have side effects like nausea, metallic taste, or diarrhea—these are temporary.
• Avoid alcohol during treatment (especially with metronidazole).
• You’ll need a follow-up test to make sure the infection is gone.

Smartphrase snippets#

.GERDTYPICAL Typical GERD symptoms without alarm features. Plan: lifestyle modifications discussed (weight loss, elevate HOB, avoid late meals, avoid triggers). Starting PPI [omeprazole 20 mg daily] x 4–8 weeks. Will reassess response and attempt step-down if improved. Discussed return precautions (dysphagia, weight loss, bleeding).

.DYSPEPSIAHPYLORI Dyspepsia, age <60, no alarm features. Plan: H. pylori testing with [urea breath test/stool antigen]. If positive, will treat with [regimen]. If negative, will trial PPI x 4–8 weeks. Discussed alarm features requiring earlier evaluation.

.GERDREFRACTORY GERD symptoms refractory to [X weeks] of PPI therapy. Confirmed proper adherence and timing. Plan: EGD to evaluate for erosive esophagitis, Barrett’s, or alternative diagnosis. GI referral placed. Continue PPI pending evaluation.

Related pages#

• GERD (problem) — comprehensive chronic GERD management, long-term PPI considerations, Barrett’s surveillance
• Irritable Bowel Syndrome (problem) — functional GI disorder often overlapping with functional dyspepsia
• Chest Pain (complaint) — cardiac causes of epigastric/chest discomfort
• Nausea/Vomiting (complaint) — related GI symptom evaluation