Gastro-oesophageal reflux disease

Red Flags

Alarm features (dysphagia, weight loss, GI bleeding, anaemia, persistent vomiting, age >50 with new symptoms) — endoscopy regardless of reflux severity^[1]
Refractory GERD on twice-daily PPI for ≥8 weeks — endoscopy + ambulatory pH/impedance; confirm reflux vs functional disorder before escalation^[1]
Barrett's oesophagus on endoscopy — surveillance per histology grade; refer for radiofrequency ablation if dysplasia^[1]
Suspected eosinophilic oesophagitis (dysphagia, food impaction, atopy) — biopsy mandatory at endoscopy; PPI plus ICS topical^[1]

First-line treatment

Interventions

Lifestyle modification^[1]
Weight reduction if BMI ≥25, head-of-bed elevation, avoid late meals (≥3 hours pre-bed), reduce trigger foods (spicy, fatty, citrus, chocolate, mint), smoking cessation, alcohol moderation
Anti-reflux surgery (fundoplication)^[1]
PPI-refractory or PPI-intolerant patients with confirmed reflux on pH monitoring; preoperative manometry mandatory
Magnetic sphincter augmentation (LINX)^[1]
Selected refractory GERD; alternative to fundoplication; preserves ability to belch and vomit

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Pantoprazole or omeprazole (PPI)^[1]	Proton pump inhibitor	Pantoprazole 40 mg or omeprazole 20–40 mg PO once daily 30–60 min before breakfast for 4–8 weeks; step down to lowest effective dose for maintenance	Per weight per paediatric guidelines	First-line for symptomatic GERD; once-daily 30 min pre-breakfast better than after meals
Vonoprazan^[1]	Potassium-competitive acid blocker (P-CAB)	10–20 mg PO once daily	—	Newer acid-suppressant; faster onset, longer duration than PPI; effective for severe oesophagitis and refractory GERD
Famotidine^[1]	H2 receptor antagonist	20–40 mg PO BD	0.5 mg/kg BD	Add at bedtime in nocturnal symptoms despite daytime PPI; mild GERD alternative
Antacid (calcium carbonate or aluminium-magnesium hydroxide)^[1]	Antacid	PRN for breakthrough symptoms	—	Symptom relief layer on top of PPI; not maintenance therapy

Pantoprazole or omeprazole (PPI)^[1]

Proton pump inhibitor

Adult: Pantoprazole 40 mg or omeprazole 20–40 mg PO once daily 30–60 min before breakfast for 4–8 weeks; step down to lowest effective dose for maintenance
Paediatric: Per weight per paediatric guidelines

First-line for symptomatic GERD; once-daily 30 min pre-breakfast better than after meals

Vonoprazan^[1]

Potassium-competitive acid blocker (P-CAB)

Adult: 10–20 mg PO once daily
Paediatric: —

Newer acid-suppressant; faster onset, longer duration than PPI; effective for severe oesophagitis and refractory GERD

Famotidine^[1]

H2 receptor antagonist

Adult: 20–40 mg PO BD
Paediatric: 0.5 mg/kg BD

Add at bedtime in nocturnal symptoms despite daytime PPI; mild GERD alternative

Antacid (calcium carbonate or aluminium-magnesium hydroxide)^[1]

Antacid

Adult: PRN for breakthrough symptoms
Paediatric: —

Symptom relief layer on top of PPI; not maintenance therapy

Safety-net

Take PPI 30–60 minutes before food (typically breakfast) — taking it after meals is much less effective^[1]
Long-term PPI use is generally safe but consider periodic dose review; B12 and bone density monitoring not routinely required^[1]
New difficulty swallowing, food sticking, weight loss, or vomiting blood — same-day medical review and likely endoscopy^[1]

Referral criteria

Alarm features (dysphagia, weight loss, GI bleed, anaemia, persistent vomiting, age >50 with new symptoms)Gastroenterology for endoscopy^[1]
Refractory GERD on twice-daily PPI ≥8 weeksGastroenterology for endoscopy + pH monitoring^[1]
Barrett's oesophagusGastroenterology for surveillance and ablation as indicated^[1]
Anti-reflux surgery candidacyUpper GI surgery with manometry and pH testing^[1]

Clinical summary

Diagnosis and stepped management of GERD in adults — lifestyle plus PPI for typical symptoms; endoscopic evaluation for alarm features.

References

1.Indian Society of Gastroenterology Guidelines on Gastroesophageal Reflux Disease (2022); ACG Clinical Guideline for GERD (2022) (2022)

Drug

Class

Adult

Paediatric

Notes

Pantoprazole or omeprazole (PPI)^[1]

Proton pump inhibitor

Pantoprazole 40 mg or omeprazole 20–40 mg PO once daily 30–60 min before breakfast for 4–8 weeks; step down to lowest effective dose for maintenance

Per weight per paediatric guidelines