Gastrointestinal

Heartburn (retrosternal burning) and acid regurgitation, often worse after meals, when lying down, or with bending over. It is a clinical diagnosis when typical symptoms occur without alarm features.

Lifestyle modification (weight loss, head-of-bed elevation, avoiding late meals and triggers) plus an empiric trial of a once-daily PPI for 8 weeks. Reassess response after the trial.

Dysphagia, odynophagia, unintentional weight loss, GI bleeding (hematemesis, melena), iron-deficiency anemia, persistent vomiting, and new-onset symptoms in patients over age 50-60. These suggest complications or malignancy.

Attempt to step down to the lowest effective dose or on-demand therapy. Patients with Barrett esophagus, severe erosive esophagitis, or relapse on withdrawal may need continued maintenance PPI.

Metaplasia of the distal esophageal squamous epithelium to columnar (intestinal) epithelium from chronic GERD; it is a premalignant condition for esophageal adenocarcinoma. Manage with maintenance PPI and refer for periodic endoscopic surveillance.

Epigastric pain, often gnawing or burning; duodenal ulcer pain may improve with food, gastric ulcer pain may worsen with food. The two leading causes are H. pylori infection and NSAID use.