GERD & peptic ulcer disease

GERD — prove it only if you must

Heartburn after spicy food, coffee, chocolate, alcohol, or reclining; regurgitation, sour taste on waking, globus, chronic cough, hoarseness, asthma flares, or chest pain. The diagnosis is clinical when the story is typical and there are no alarm features (ACG: ).

Alarm vs empiric PPI

No alarm
8-week PPI trial
Once-daily PPI 30 min before breakfast, or a short 1–2 week high-dose BID trial. Reassess at 4–8 weeks; step up to high-dose then BID if incomplete.
Alarm
EGD, do not trial forever
Dysphagia / odynophagia, weight loss, GIB, IDA, persistent vomiting, anorexia, or new onset at age ≥60. Incomplete PPI response also goes to EGD with biopsy (ideally off PPI 2–4 weeks).

Ddx: infectious or pill esophagitis, EoE, motility disorder, functional dyspepsia.

EGD negative, still symptomatic: ambulatory pH / impedance off PPI.
EGD negative plus chest pain or dysphagia: esophageal manometry.

Lifestyle, acid suppression, stop rules

Weight loss (goal BMI <25), tobacco cessation, <2 cups coffee/tea/soda, diet change, ≥30 min exercise daily.
No meals 2–3 h before bed, left-lateral sleep, head-of-bed elevation 6–8 in (JAMA IM 2021;e207238).

Maintenance PPI: recurrent symptoms after stop, or complications. Lowest effective dose. Test for reflux + EGD at 1 year if staying on therapy.
On PPI >6 months: taper by 50% per week to avoid rebound hypersecretion.
PPI risks with a probable signal: ↓ Ca / Mg / Fe absorption, AIN, C. diff and other enteric infections. Insufficient evidence for osteoporosis, CKD, or dementia (; ).
Vonoprazan (PCAB) 10 mg daily is an expensive PPI alternative ().
H2RA (famotidine 10–20 mg BID) as nightly add-on or PRN; tachyphylaxis is common after weeks. Antacids, sodium alginate (), baclofen as adjuncts.

Refractory symptoms and complications

EoE: dysphagia, GERD symptoms, food impaction; atopic history. Dx ≥15 eos/HPF. Tx: PPI, topical steroids, elimination diet, dupilumab (IL-4/13) (ACG: ).
Hiatal hernia: type I sliding; types II–IV paraesophageal. Surgery is controversial and reserved for refractory disease.
Reflux hypersensitivity: acid exposure time <4% on pH-impedance with a positive symptom association and normal manometry.
Gastric fundoplication can beat medical therapy for carefully selected refractory heartburn ().

Barrett’s and stricture

Barrett’s: squamous → intestinal metaplasia. Adenocarcinoma risk ~0.38%/yr with IM vs 0.07% without.
Screen with EGD if chronic GERD plus ≥3 risk factors: age >50, white, male, central obesity, tobacco, family Barrett’s or adenoCA (). Indefinite PPI; surveillance interval follows dysplasia.
Stricture: progressive solid-food dysphagia. Biopsy to separate peptic stricture from cancer.

Peptic ulcer disease

Intermittent gnawing, hunger-like epigastric pain relieved by antacids; early satiety, bloating, nausea, bleed (; ; ). H. pylori and NSAIDs still dominate; idiopathic ulcers are rising. Also: bisphosphonates, clopidogrel, sirolimus, ZES, mastocytosis, HSV/CMV/EBV/fungus, XRT, cocaine ischemia, Crohn’s, sarcoid, critical illness, smoking.

Test every dyspepsia patient for H. pylori. Age >60, weight loss, bleeding, or persistent vomiting → EGD to exclude cancer ().
Active-infection tests: stool antigen or urea breath test. PPI and antibiotics raise false-negatives; H2RAs do not. Biopsy urease, histology, or culture when you need susceptibility.
Biopsy malignant-appearing ulcers and selected benign-appearing ones. Most gastric ulcers need follow-up EGD at 8–12 weeks.
PPI 4–8 weeks by size and location. If a cardiac indication for aspirin exists, continue ASA with a PPI ().

H. pylori — 2024 first-line is quadruple therapy

Alternatives: rifabutin triple (PPI, rifabutin, amoxicillin × 14 d) or vonoprazan–amoxicillin dual × 14 d ().
Empiric clarithromycin triple therapy is contraindicated unless susceptibility is known.
Salvage: do not recycle failed antibiotics. Rifabutin–amoxicillin–PPI BID × 14 d matches bismuth quad eradication with better adherence (J Inf Dis 2023;228:511). Clarithromycin or levofloxacin only with confirmed susceptibility.
Test of cure in everyone: stool Ag, urea breath, or EGD ≥4 weeks after antibiotics and off PPI for 2 weeks.

Ia–IIb need endoscopic therapy plus high-dose PPI. Full UGIB playbook lives on the bleed card.

Forrest	Stigma	Rebleed without therapy
Ia	Active arterial (spurting) bleeding	85%
Ib	Oozing without a visible vessel	30%
IIa	Non-bleeding visible vessel	40%
IIb	Adherent clot	25%
IIc	Flat pigmented spot	10%
III	Clean ulcer base	3%

Refractory ulcer (5–10%): not healed after 8–12 weeks of adequate PPI. Prove H. pylori gone, stop NSAIDs, check fasting gastrin for ZES (off PPI 1 week if possible; secretin stim if nondiagnostic), hunt rare causes. Continue PPI another 12 weeks and repeat EGD. Surgery is rare (resection, vagotomy, partial gastrectomy).
Complicated ulcer = bleeding, perforation, or gastric-outlet obstruction from pyloric/duodenal scarring. Dilate or operate if medical therapy fails; always exclude malignancy in outlet obstruction.