Scope of this summary
Adults with dyspepsia, heartburn or regurgitation in ambulatory practice. Dysphagia, overt bleeding, severe chest pain, unexplained weight loss, persistent vomiting and iron-deficiency anemia can change urgency. This page does not cover pediatric disease, pregnancy-specific prescribing, Barrett surveillance, eosinophilic esophagitis or emergency gastrointestinal bleeding.
The Bottom Line
- Separate dyspepsia—predominantly epigastric pain, burning, postprandial fullness or early satiation—from classic reflux symptoms, while recognizing overlap and excluding cardiac or biliary presentations.
- For uninvestigated dyspepsia, the ACG/CAG guideline suggests upper endoscopy at age 60 years or older; younger patients generally receive noninvasive Helicobacter pylori testing and treatment if positive, with individual earlier endoscopy for meaningful cancer risk or alarm features.
- For classic heartburn and regurgitation without alarm features, use an eight-week once-daily premeal proton-pump-inhibitor trial; perform endoscopy for dysphagia or alarm features and when symptoms fail or return after an appropriate trial.
- Confirm persistent or uncertain GERD with source-directed reflux monitoring rather than escalating medication indefinitely; test off acid suppression when GERD has not already been objectively established and use impedance-pH on treatment in selected proven disease.
- Treat H. pylori using the 2024 North American guideline and document eradication with an appropriate test of cure at least four weeks after antibiotics, withholding acid suppression for the required interval.
Practical clinical workflow
1
Characterize dominant symptoms, duration, meal relation, reflux, swallowing, vomiting, bleeding, anemia, medication exposure, family history and country-of-childhood gastric-cancer risk; assess chest or right-upper-quadrant symptoms separately.
2
Choose endoscopy, H. pylori test-and-treat or an empiric proton-pump-inhibitor trial from age, risk and symptom phenotype; arrange urgent assessment rather than routine testing for active bleeding or unstable chest symptoms.
3
When prescribing a proton-pump inhibitor, give it 30–60 minutes before a meal, review adherence and indication, and use the lowest effective maintenance strategy after response unless severe erosive disease or another reason requires continued therapy.
4
After a positive H. pylori result, select a 14-day regimen from antibiotic exposure, allergy and susceptibility; avoid empiric clarithromycin- or levofloxacin-containing salvage therapy unless susceptibility is demonstrated.
5
Reassess persistent symptoms for functional dyspepsia, reflux hypersensitivity, motility disease, medication effects and non-GI causes; use gastroenterology referral and physiologic testing instead of repeated unstructured medication switches.
Safety boundaries and escalation
- Hematemesis, melena, syncope, hemodynamic compromise, progressive dysphagia, food impaction or severe chest pain requires urgent or emergency evaluation.
- Do not attribute possible acute coronary syndrome to reflux without appropriate cardiac assessment; symptom response to an antacid or proton-pump inhibitor does not exclude cardiac disease.
- Confirm pregnancy, renal function, interactions, allergy and antimicrobial history before H. pylori treatment; bismuth, tetracycline and other regimen components are not interchangeable across patients.
- Long-term proton-pump-inhibitor concerns should be discussed accurately without stopping a clearly indicated therapy abruptly; periodically reassess indication, dose and objective disease status.
Localization
The US dyspepsia threshold and ACG GERD testing sequence are source-specific. Use FDA labels, local endoscopy access and the 2024 North American H. pylori resistance framework.
Source documents
Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.
- American College of GastroenterologyACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux DiseaseDOI 10.14309/ajg.0000000000001538 · published 2022-01-01 · accessed 2026-08-20view source
- American College of Gastroenterology and Canadian Association of GastroenterologyACG and CAG Clinical Guideline: Management of DyspepsiaDOI 10.1038/ajg.2017.154 · published 2017-07-01 · accessed 2026-08-20view source
- American College of GastroenterologyACG Clinical Guideline: Treatment of Helicobacter pylori InfectionDOI 10.14309/ajg.0000000000002968 · published 2024-09-01 · accessed 2026-08-20view source
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