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gi.gerd.core.v1PRODUCTION
gi.gerd.core.v1

GERD (chronic, empiric-to-maintenance)

gastroenterologychronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm GERD scope: typical reflux symptoms amenable to empiric PPI vs refractory GERD vs Barrett surveillance (ACG 2022 Katz)

Inputs
1
Actions
0
Advance rule
Set
Advance when

pathway assigned: empiric, refractory, or Barrett

Patient inputs (14)

EGD threshold for alarm symptoms; Barrett risk stratification (ACG 2022 Katz)

Male sex is Barrett risk factor (AGA 2024 Barrett)

Prior PPI response defines empiric vs refractory pathway (ACG 2022 Katz)

Chronic heartburn >5 yr + 3 Barrett risk factors = EGD screening (AGA 2024 Barrett)

NSAIDs, bisphosphonates, calcium channel blockers worsen GERD; PPI drug interactions (ACG 2022 Katz)

Symptom frequency guides empiric vs step-up PPI (ACG 2022 Katz)

Dysphagia, odynophagia, weight loss, GI bleeding, anemia, vomiting = EGD indication (ACG 2022 Katz)

EGD for alarm symptoms, refractory GERD, Barrett screening/surveillance (ACG 2022 Katz; AGA 2024 Barrett)

Ambulatory pH-impedance testing for refractory GERD — gold standard (Lyon Consensus 2018)

High-resolution manometry pre-surgical evaluation or if motility disorder suspected (ACG 2022 Katz)

Obesity is independent GERD risk factor; weight loss is therapeutic (ACG 2022 Katz)

Barrett/EAC family history raises screening priority (AGA 2024 Barrett)

Smoking is Barrett risk factor (AGA 2024 Barrett)

Anemia screen if alarm symptoms (iron-deficiency from erosive esophagitis or Barrett) (ACG 2022 Katz)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (3)

3 need judgement
  • informationalseverealarm_symptoms_present
    Dysphagia, odynophagia, GI bleeding, iron-deficiency anemia, unintentional weight loss, or recurrent vomiting in GERD patient (ACG 2022 Katz)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebarrett_with_hgd
    Barrett esophagus with high-grade dysplasia confirmed on expert pathology review (AGA 2024 Barrett)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesevere_erosive_esophagitis
    LA grade C or D erosive esophagitis on EGD (ACG 2022 Katz)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

GERD empiric PPI step-up / step-down / maintenance — ACG 2022 Katz
axis: gerd_empiric_step_axisstep 1 - Step 1 — Empiric PPI standard dose x 8 weeks
Selected step "Step 1 — Empiric PPI standard dose x 8 weeks" — Typical GERD symptoms (heartburn, regurgitation) without alarm features
  • omeprazole
    first line
    PPI
    20 mg PO daily 30 min before breakfast • PO • daily
    ACG 2022 Katz — standard-dose PPI x 8 wk is first-line diagnostic-therapeutic maneuver
    rxcui 7646
  • lansoprazole
    first line
    PPI
    30 mg PO daily 30 min before breakfast • PO • daily
    ACG 2022 Katz — alternative standard-dose PPI
    rxcui 17128
  • esomeprazole
    first line
    PPI
    20 mg PO daily 30 min before breakfast • PO • daily
    ACG 2022 Katz — alternative PPI; S-isomer of omeprazole
    rxcui 283742
  • pantoprazole
    first line
    PPI
    40 mg PO daily 30 min before breakfast • PO • daily
    ACG 2022 Katz — alternative PPI; fewer CYP2C19 interactions
    rxcui 40790
  • rabeprazole
    first line
    PPI
    20 mg PO daily • PO • daily
    ACG 2022 Katz — alternative PPI
    rxcui 114979
  • dexlansoprazole
    first line
    PPI
    30 mg PO daily • PO • daily
    ACG 2022 Katz — dual-release PPI; may be taken without regard to meals
    rxcui 816346

outpatient playbook — drug actions (5)

  1. 1. PPI standard dose daily x 8 wk
    Omeprazole 20 mg or equivalent • PO • daily before breakfast
    trigger: Typical GERD symptoms, no alarms
    ACG 2022 Katz
  2. 2. PPI step-down or on-demand
    Lowest effective dose or PRN • PO • daily or PRN
    trigger: Symptom resolution at 8 wk
    ACG 2022 Katz — minimize long-term exposure
  3. 3. PPI BID 8 wk
    Omeprazole 20 mg BID or equivalent • PO • BID
    trigger: Partial response to daily PPI
    ACG 2022 Katz step-up
  4. 4. H2RA bedtime add-on
    Famotidine 20-40 mg QHS • PO • QHS
    trigger: Nocturnal acid breakthrough on PPI
    ACG 2022 Katz
  5. 5. Vonoprazan
    20 mg PO daily • PO • daily
    trigger: Refractory to PPI BID + confirmed on pH-impedance
    PHALCON Laine 2023

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Heartburn / pyrosis; Regurgitation / acid reflux; Dysphagia (alarm symptom).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**GERD (chronic, empiric-to-maintenance)** (gi.gerd.core.v1).
Phenotype framing: Erosive esophagitis (LA grade A-D), NERD, Barrett esophagus +/- dysplasia, eosinophilic esophagitis, functional heartburn, achalasia, rumination (ACG 2022 Katz; Lyon Consensus 2018)
Scope: Confirm GERD scope: typical reflux symptoms amenable to empiric PPI vs refractory GERD vs Barrett surveillance (ACG 2022 Katz)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GERD empiric PPI step-up / step-down / maintenance — ACG 2022 Katz** — step "Step 1 — Empiric PPI standard dose x 8 weeks".
1. omeprazole 20 mg PO daily 30 min before breakfast PO daily (PPI, first line) — ACG 2022 Katz — standard-dose PPI x 8 wk is first-line diagnostic-therapeutic maneuver
2. lansoprazole 30 mg PO daily 30 min before breakfast PO daily (PPI, first line) — ACG 2022 Katz — alternative standard-dose PPI
3. esomeprazole 20 mg PO daily 30 min before breakfast PO daily (PPI, first line) — ACG 2022 Katz — alternative PPI; S-isomer of omeprazole
4. pantoprazole 40 mg PO daily 30 min before breakfast PO daily (PPI, first line) — ACG 2022 Katz — alternative PPI; fewer CYP2C19 interactions
5. rabeprazole 20 mg PO daily PO daily (PPI, first line) — ACG 2022 Katz — alternative PPI
6. dexlansoprazole 30 mg PO daily PO daily (PPI, first line) — ACG 2022 Katz — dual-release PPI; may be taken without regard to meals

Setting playbook (outpatient) — Empiric PPI trial 8 wk for typical symptoms; step-down to lowest effective dose; EGD for alarm symptoms or refractory; Barrett surveillance; lifestyle optimization
7. PPI standard dose daily x 8 wk Omeprazole 20 mg or equivalent PO daily before breakfast — Typical GERD symptoms, no alarms (ACG 2022 Katz)
8. PPI step-down or on-demand Lowest effective dose or PRN PO daily or PRN — Symptom resolution at 8 wk (ACG 2022 Katz — minimize long-term exposure)
9. PPI BID 8 wk Omeprazole 20 mg BID or equivalent PO BID — Partial response to daily PPI (ACG 2022 Katz step-up)
10. H2RA bedtime add-on Famotidine 20-40 mg QHS PO QHS — Nocturnal acid breakthrough on PPI (ACG 2022 Katz)
11. Vonoprazan 20 mg PO daily PO daily — Refractory to PPI BID + confirmed on pH-impedance (PHALCON Laine 2023)

Non-pharmacologic actions:
- Weight loss if BMI >25 — strongest lifestyle intervention (ACG 2022 Katz)
- Head-of-bed elevation 6-8 inches for nocturnal symptoms (ACG 2022 Katz)
- Avoid meals 2-3 hours before bedtime (ACG 2022 Katz)
- Dietary trigger avoidance (individualized — common: coffee, chocolate, spicy, citrus, alcohol) (ACG 2022 Katz)
- Smoking cessation (NICE 2024)
- PPI timing education: 30-60 min before first meal of the day (ACG 2022 Katz)

AVOID / contraindication checks:
- PPI long term risks — counsel on C. diff, hypomagnesemia, bone fracture, B12 deficiency, CKD but do NOT withhold when indicated (ACG 2022 Katz)
- Clopidogrel avoid omeprazole/esomeprazole (CYP2C19 interaction) — use pantoprazole or rabeprazole (ACG 2022 Katz)
- Methotrexate PPI interaction — monitor for delayed MTX clearance (ACG 2022 Katz)
- H2RA tachyphylaxis — tolerance develops within 2 6 wk of continuous use (ACG 2022 Katz)

Monitoring

Regimen monitoring:
- Symptom reassessment at 8 wk of empiric PPI (ACG 2022 Katz)
- PPI step-down attempt after symptom resolution — lowest effective dose or on-demand (ACG 2022 Katz)
- Barrett surveillance: no dysplasia q3-5yr EGD; LGD q6-12mo; HGD/post-ablation q3mo x1yr then annually (AGA 2024 Barrett)
- Long-term PPI: annual Mg if on diuretics; B12 if >3 yr; bone density if additional risk factors (ACG 2022 Katz)

Setting (outpatient) monitoring:
- Symptom reassessment at 8 wk (ACG 2022 Katz)
- Annual PPI step-down attempt (ACG 2022 Katz)
- Barrett surveillance EGD per AGA 2024 intervals
- Long-term PPI safety labs as indicated (Mg, B12) (ACG 2022 Katz)

Follow-up plan: Symptom reassessment at 8 wk; lifestyle reinforcement (weight loss, head-of-bed elevation, avoid late meals); long-term PPI safety counseling (bone, Mg, C. diff) (ACG 2022 Katz; NICE 2024)
- Close-out criterion: follow-up scheduled

Monitoring phase: PPI step-down attempt after 8 wk; Barrett surveillance EGD intervals (no dysplasia q3-5yr, LGD q6-12mo, post-ablation q3mo then annually) (AGA 2024 Barrett; ACG 2022 Katz)

Disposition

Current setting: outpatient — Empiric PPI trial 8 wk for typical symptoms; step-down to lowest effective dose; EGD for alarm symptoms or refractory; Barrett surveillance; lifestyle optimization

Disposition criteria:
- Maintain outpatient unless complication (stricture, severe erosive esophagitis LA grade C/D, bleeding)
- GI referral for refractory GERD, Barrett, surgical candidacy evaluation (ACG 2022 Katz)

Escalation triggers (move to higher acuity):
- Alarm symptoms (dysphagia, weight loss, GI bleed, anemia) then urgent EGD (ACG 2022 Katz)
- Refractory symptoms after PPI BID 8 wk then GI referral for EGD + pH-impedance (ACG 2022 Katz)
- Barrett with dysplasia then GI referral for endoscopic eradication therapy (AGA 2024 Barrett)

Patient Action Plan

**GERD symptom management action plan**
Personalised values: baseline_symptom_frequency, current_ppi_dose, barrett_status.

**Well controlled — continue maintenance** (green):
Triggers:
- Heartburn <1x/week or none
- No regurgitation
- No dysphagia
- Sleeping well, no nocturnal symptoms
Actions:
- Continue current PPI at lowest effective dose (or on-demand if stepped down)
- Maintain lifestyle modifications (weight, diet, meal timing, head-of-bed elevation)
- Keep Barrett surveillance EGD appointments if applicable
- Annual PPI step-down attempt with provider

**Worsening — contact provider within 1 week** (yellow):
Triggers:
- Heartburn >2x/week despite PPI
- Regurgitation interfering with sleep or meals
- Mild difficulty swallowing (occasional, solids only)
- Need for daily antacids on top of PPI
Actions:
- Verify PPI timing (30-60 min before breakfast)
- Reinforce lifestyle: avoid late meals, elevate head of bed
- Schedule appointment with provider to discuss step-up or EGD
Contact provider when:
- Symptoms not improving after 2 weeks of adherence to PPI + lifestyle
- New or worsening regurgitation

**Alarm — seek urgent evaluation** (red):
Triggers:
- Difficulty swallowing solids or liquids (progressive dysphagia)
- Painful swallowing (odynophagia)
- Vomiting blood or coffee-ground material
- Black tarry stools
- Unintentional weight loss >5% in 3 months
- Food impaction (cannot swallow saliva)
Actions:
- Stop eating/drinking if food impaction — go to ED
- Seek urgent/emergent evaluation for GI bleeding (ED)
- Contact GI for urgent EGD referral
Contact provider when:
- Any red zone symptom — do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Dysphagia, odynophagia, GI bleeding, iron-deficiency anemia, unintentional weight loss, or recurrent vomiting in GERD patient (ACG 2022 Katz)
- [SEVERE] Barrett esophagus with high-grade dysplasia confirmed on expert pathology review (AGA 2024 Barrett)
- [MODERATE] LA grade C or D erosive esophagitis on EGD (ACG 2022 Katz)

Citations

- ACG 2022 Clinical Guideline: Diagnosis and Management of GERD (Katz Gastroenterology 2022) [PMID:34807007](https://pubmed.ncbi.nlm.nih.gov/34807007/)
- Cited evidence (PMID 29437910) [PMID:29437910](https://pubmed.ncbi.nlm.nih.gov/29437910/)
- Cited evidence (PMID 36228734) [PMID:36228734](https://pubmed.ncbi.nlm.nih.gov/36228734/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACG 2022 Clinical Guideline: Diagnosis and Management of GERD (Katz Gastroenterology 2022) — PMID:34807007
  • Cited evidence (PMID 29437910) — PMID:29437910
  • Cited evidence (PMID 36228734) — PMID:36228734