Decision support only — not a substitute for gastroenterology, pathology review or local endoscopy policy. Food bolus with inability to handle secretions, haematemesis, perforation features or airway compromise is an urgent problem, not a chronic clinic pathway. Small green tags identify the guideline or trial supporting selected high-value decisions. Verify doses and product availability locally.
1 Start with the dominant phenotype
“Reflux” is a symptom label, not a licence to ignore dysphagia. First decide whether the problem is acid-mediated, oropharyngeal, obstructive/motility-related, or an established mucosal disorder.
Oesophageal symptom or known oesophageal diseaseHeartburn/regurgitation · dysphagia/food sticking · odynophagia · Barrett’s/EoE follow-up
Any alarm feature or acute obstruction?
NO → phenotype below
YES → EXPEDITEProgressive dysphagia, weight loss, GI bleeding/iron deficiency, persistent vomiting, odynophagia, abnormal imaging, or new symptoms in a higher-risk patient: early UGI endoscopy. Complete food-bolus obstruction or inability to manage secretions needs urgent endoscopic assessment.
TYPICAL REFLUX
Heartburn/regurgitation, no alarm: optimised once-daily PPI for 8 weeks. Reassess the diagnosis and indication, not just symptom intensity.
Atypical/extra-oesophageal alone: investigate competing ENT, respiratory and cardiac causes; objective reflux testing is more useful than serial empiric PPIs.
OROPHARYNGEAL
Difficulty initiating, cough/choke, wet voice, nasal regurgitation: swallow/aspiration assessment, speech pathology, VFSS or FEES as appropriate.
Do not send every “dysphagia” straight to manometry. The anatomical level comes first.
OESOPHAGEAL DYSPHAGIA
Solids ± liquids sticking after initiation: UGI endoscopy with mucosal assessment and biopsies. Biopsy for EoE even when the lumen looks fairly normal.
No mechanical/mucosal cause: high-resolution manometry; timed barium oesophagram with tablet and/or FLIP can answer specific residual questions.
KNOWN BARRETT’S / EoE
Barrett’s: confirm segment, intestinal metaplasia and dysplasia status; use a protocolled surveillance or eradication pathway.
EoE: symptoms plus biopsies drive control. Treat inflammation and fibrostenosis in parallel; dilation alone leaves the disease active.
2 Dysphagia — phenotype, then test
| Pattern | Clues | Likely bucket | First useful move |
|---|
| Initiation problem | Coughing, choking, wet voice, nasal regurgitation, aspiration, neurologic disease | Oropharyngeal dysphagia | Bedside swallow screen/SLP; VFSS or FEES. Stabilise nutrition and aspiration risk. |
| Solids first | Progressive = malignancy/peptic stricture; intermittent = ring or EoE | Mechanical obstruction | UGI endoscopy. Biopsy lesions and sample for EoE where plausible. |
| Solids + liquids | From onset, regurgitation, chest pain, weight loss, nocturnal cough | Achalasia or other motility disorder | Endoscopy first to exclude structural disease/pseudoachalasia, then high-resolution manometry. |
| Painful swallow | Immunosuppression, recent tablets, radiation, ulceration, oral candidiasis | Infectious, pill, reflux or other oesophagitis | Early endoscopy if severe, persistent, bleeding or immunocompromised; biopsy/brush targeted lesions. |
Endoscopy
- FindsCancer, stricture, ring, retained food, reflux injury, Barrett’s, EoE and infection.
- BiopsyVisible lesions; suspected Barrett’s; and at least 6 oesophageal biopsies from 2 levels when EoE is possible.
Physiology
- HRMReference test after a mechanical cause is excluded; classifies achalasia and major motility disorders. ACG PHYSIOLOGY 2020
- FLIPUseful adjunct where HRM is borderline, incomplete or discordant; can assess EGJ opening during sedated endoscopy.
Barium is complementary
- Good forSubtle rings, tight narrowing, anatomy, aspiration and timed emptying; add a barium tablet for obstructive symptoms. ACG PHYSIOLOGY 2020
- Not enoughA routine oesophagram is a poor screen for dysmotility. A “normal” study does not replace HRM when suspicion remains.
3 GORD — control symptoms, then earn the long-term label
Uncomplicated typical symptoms
- TrialPPI once daily × 8 weeks, 30–60 minutes before breakfast. ACG GORD 2022
- ExamplesStandard reflux doses include omeprazole 20 mg, pantoprazole 40 mg, lansoprazole 30 mg or rabeprazole 20 mg daily; product indications differ.
- ResponseIf controlled and no ongoing indication, step down, use on demand or attempt cessation. GESA EVOLVE · AGA 2022
Make the PPI trial fair
- TimingBefore a meal, not at bedtime. If twice daily, before breakfast and the evening meal.
- CheckAdherence, symptom phenotype and the actual indication before escalating. One switch to another PPI is reasonable; repeated switches add little.
- AdjunctAlginate/antacid for breakthrough symptoms. An intermittent bedtime H2 blocker may help nocturnal symptoms, but tachyphylaxis develops.
Targeted non-drug measures
- WeightWeight loss if overweight/obese has the clearest lifestyle signal.
- NightAvoid meals within 2–3 hours of bed; elevate the bed head and consider left-lateral sleep for nocturnal reflux.
- TriggersAvoid only reproducible triggers. Blanket bans on coffee, spice, chocolate and citrus are rarely worth the paperwork.
| Clinical state | Maintenance approach | Review point |
|---|
| No erosive disease / no Barrett’s | Lowest effective dose; on-demand PPI is reasonable if symptoms permit. | Reconfirm indication at least annually and after major weight/medication changes. |
| LA A–B healed | Step down if controlled; continue if relapse is prompt or burdensome. | Persistent symptoms or dysphagia should trigger diagnostic review, not indefinite blind escalation. |
| LA C–D / peptic stricture | Long-term PPI, usually indefinite, or appropriately selected antireflux surgery. | Confirm healing and exclude Barrett’s/other pathology after treatment. |
| Barrett’s oesophagus | At least once-daily PPI unless contraindicated; surveillance/EET follows histology and length. | PPI is for reflux control and possible chemoprevention; aspirin is not added solely for Barrett’s. |
4 “Refractory reflux” — establish what is refractory
Persistent symptoms on a PPI can be ongoing reflux, reflux hypersensitivity, functional heartburn, rumination, supragastric belching, EoE, achalasia or cardiac disease. Symptom response alone cannot separate them.
Objective GERD not yet established
- ScopeUGI endoscopy off PPI for 2–4 weeks if safe; biopsy when EoE is in the differential. ACG GORD 2022
- Reflux testIf endoscopy is non-diagnostic, ambulatory pH or pH-impedance monitoring off PPI.
- NegativeIf reflux testing is negative and no other indication exists, stop the PPI and look for the actual cause.
Objective GERD already established
- OptimiseConfirm timing/adherence; selected patients can trial twice-daily dosing before further testing.
- On PPIPersistent symptoms despite an adequate twice-daily trial → impedance-pH monitoring on PPI to relate symptoms to acid/non-acid events. ACG GORD 2022
- Before opHigh-resolution manometry before antireflux surgery/endoscopic therapy to exclude achalasia and absent contractility.
Extra-oesophageal symptoms
Chronic cough, dysphonia and throat symptoms are non-specific. Without typical heartburn/regurgitation, test for reflux before committing to PPI therapy. Laryngoscopy or endoscopy alone does not prove reflux causation.
PPI safety: keep the proportions straight COMPASS 2019
Most alarming long-term associations come from observational data with confounding. Randomised safety data did not reproduce most signals, apart from a possible small increase in enteric infection. Review the indication; do not stop a needed PPI because of a headline.
5 Reflux oesophagitis, ulcer and peptic stricture
| LA grade | Endoscopic definition | Practical implication |
|---|
| A | One or more mucosal breaks ≤5 mm, not extending between the tops of folds. | Mild; not by itself definitive proof that every symptom is reflux-mediated. |
| B | At least one break >5 mm, not continuous between the tops of folds. | Treat to heal. Current ANZ quality guidance advises repeat UGI endoscopy after treatment for B–D. |
| C | Breaks continuous between at least two fold tops, involving <75% of circumference. | Objective severe GORD; long-term PPI or selected surgery after healing. |
| D | Mucosal breaks involving ≥75% of circumference. | Severe disease; maintenance treatment and follow-up endoscopy are expected. |
Heal, then look again
- CoursePPI at healing dose for 8 weeks; use a high-dose regimen for severe disease per product/local protocol.
- RepeatFor LA B/C/D, repeat UGI endoscopy after 6–8 weeks of high-dose PPI to document healing and exclude concealed Barrett’s or malignancy. ANZ UGI 2025
Ulcer / non-healing disease
- BiopsyBiopsy an oesophageal ulcer ≥5 mm and non-healing oesophagitis; target edges/base according to suspected cause. ANZ UGI 2025
- RecheckAdherence, pill injury, infection, EoE, malignancy, radiation/caustic injury and Crohn disease.
Stricture
- ExcludeBiopsy to exclude malignancy before calling it peptic.
- TreatEndoscopic dilation plus durable acid suppression. Recurrent/refractory strictures need specialist techniques and diagnostic review.
6 Barrett’s oesophagus — define it properly, then act on histology
Diagnosis & screening
- DefineColumnar mucosa in the tubular oesophagus extending ≥1 cm, with intestinal metaplasia on biopsy. Record Prague C and M lengths.
- Do notDo not routinely biopsy a normal Z-line or an irregular Z-line <1 cm without a visible abnormality.
- ScreenConsider one screening endoscopy for chronic GORD plus ≥3 additional risks: male sex, age >50, White ethnicity, smoking, obesity or first-degree family history of Barrett’s/EAC.
High-quality sampling
- InspectHigh-definition inspection; resect/biopsy visible lesions before random biopsies.
- SeattleFour-quadrant biopsies every ≤2 cm for non-dysplastic surveillance; use tighter sampling in dysplasia protocols. ANZ UGI 2025 · ACG BARRETT 2022
- PathologyAny dysplasia needs confirmation by a second pathologist with GI expertise.
Length- and histology-based surveillance intervals ACG BARRETT 2022
| Histology / segment | Action | Interval if surveillance |
|---|
| NDBE <3 cm | Daily PPI; risk-factor management. No ablation. | Every 5 years after a high-quality baseline examination. |
| NDBE ≥3 cm | Daily PPI; ensure protocolled inspection/biopsies. | Every 3 years. |
| Indefinite for dysplasia | Increase/optimise PPI to twice daily, then repeat UGI endoscopy with biopsies. | Within 6 months; if still indefinite, annual surveillance. |
| Confirmed LGD | Endoscopic eradication therapy (EET) is generally favoured; surveillance is a reasonable informed alternative. ACG BARRETT 2022 · SURF | If surveilling: 6 months, 12 months, then annually while LGD persists. |
| HGD / intramucosal cancer | Refer to an expert Barrett’s centre for endoscopic resection of visible lesions plus ablation of residual Barrett’s. | Structured post-eradication surveillance; interval depends on worst pretreatment histology. |
Local guideline caveat
Cancer Council Australia’s Barrett’s guideline remains a useful local framework but was published in 2014 and its own page warns that it may no longer reflect current evidence. The length-stratified intervals above follow the 2022 ACG update; align the final plan with the treating Australian endoscopy service.
Chemoprevention claims
Use a daily PPI. Do not add aspirin solely to prevent oesophageal adenocarcinoma, and do not offer antireflux surgery as a cancer-prevention procedure. Treat cardiovascular risk and reflux on their own merits.
7 Eosinophilic oesophagitis — inflammation plus remodelling
Diagnose ACG EoE 2025 · ANZ UGI 2025
- ClinicalSymptoms of oesophageal dysfunction, often dysphagia, food impaction or adaptive eating.
- Histology≥15 eosinophils/high-power field after evaluating other contributors to oesophageal eosinophilia.
- Biopsy≥6 targeted biopsies from 2 levels; record EREFS and quantify eosinophils at follow-up.
Choose first-line anti-inflammatory therapy ACG EoE 2025
- PPIOmeprazole 20 mg BD or 40 mg daily, or equivalent high-dose PPI.
- SteroidSwallowed budesonide 2–4 mg/day or fluticasone 1760 micrograms/day, divided; nothing by mouth for 30–60 minutes after.
- DietStart with a less restrictive empiric 1-food or 2-food elimination diet with dietitian support. Do not use allergy tests to choose foods.
Fibrostenosis
- DilateGradual endoscopic dilation for a clinically relevant stricture/narrow-calibre oesophagus.
- AlwaysDilation is not monotherapy. Continue anti-inflammatory treatment to reduce recurrence and further remodelling.
- EscalateDupilumab is a specialist step-up option after inadequate response/intolerance or with relevant comorbid atopy; confirm current TGA/PBS access. LIBERTY EoE TREET
Symptoms can lie
Patients compensate by chewing, drinking with meals and avoiding dense foods. Assess response with symptoms and repeat endoscopy/biopsy, not symptoms alone. Continue the therapy that achieved histologic remission; EoE usually recurs when treatment stops.
8 Other oesophagitis, procedures & follow-up
Pill injury
- CulpritsDoxycycline/tetracyclines, bisphosphonates, NSAIDs, potassium, iron and selected antimicrobials.
- DoStop/substitute where possible; full glass of water, remain upright ≥30 minutes, avoid dosing immediately before bed. Scope persistent/severe odynophagia or bleeding.
Infectious oesophagitis
- CandidaSystemic antifungal therapy; reconsider immune status, steroids/antibiotics and HIV risk.
- HSV/CMVUsually immunocompromised; endoscopic pattern plus histology/virology guides antiviral treatment. Dose to renal function and involve ID/transplant teams where relevant.
Caustic, radiation or perforation concern
- CausticPoison centre/toxicology and urgent specialist pathway. Do not induce vomiting or neutralise blindly.
- PerforationSevere chest pain, sepsis, subcutaneous emphysema or post-procedure deterioration → NBM, IV therapy, urgent CT and surgical/upper-GI input.
Procedural choices
- GORDAntireflux surgery for objectively proven reflux with persistent troublesome regurgitation, severe erosive disease or large hiatus hernia after physiology and shared decision-making.
- AchalasiaPOEM, laparoscopic Heller myotomy or pneumatic dilation according to subtype, expertise and reflux trade-off; botulinum toxin mainly for patients unfit for definitive therapy. ACG ACHALASIA 2020
- ObesityRoux-en-Y gastric bypass may address GORD in an appropriate bariatric candidate; sleeve gastrectomy can worsen reflux.
Write the follow-up plan
- PPIRecord indication, intended dose and whether cessation is unsafe (LA C/D, Barrett’s, peptic stricture, high GI-bleed risk).
- DysphagiaDocument nutrition/weight, aspiration risk, food impaction history and the next test if endoscopy is unrevealing.
- SurveillanceRecord Barrett’s length/histology and next UGI date; for EoE, record current therapy and planned histologic reassessment.
Primary sources. Australian & New Zealand joint position statement, Quality Upper Gastrointestinal Endoscopy (2025); Cancer Council Australia, Clinical practice guidelines for the diagnosis and management of Barrett’s oesophagus and early oesophageal adenocarcinoma (2014, explicitly marked for review); GESA/RACP Evolve PPI recommendations; ASCIA, Eosinophilic Oesophagitis Management Plan (Oct 2025); ACG GERD guideline (2022); ACG Barrett’s guideline update (2022); ACG oesophageal physiologic testing guideline (2020); ACG achalasia guideline (2020); ACG EoE guideline (2025); AGA PPI deprescribing update (2022).
Key trials. SURF (RFA vs surveillance for confirmed Barrett’s LGD, JAMA 2014); AIM Dysplasia (RFA for dysplastic Barrett’s, NEJM 2009); AspECT (high-dose PPI ± aspirin, Lancet 2018); COMPASS pantoprazole safety analysis (Gastroenterology 2019); EOS studies of budesonide orodispersible therapy; LIBERTY EoE TREET (dupilumab, NEJM 2022).
Caveats. Australian Barrett’s guidance is older than the current ACG interval framework. Local endoscopy services may use different surveillance intervals, pathology pathways and access criteria. EoE formulations, biologic registration/PBS status and compounded-product instructions can change. eTG was not publicly accessible during compilation. Verify doses, drug interactions, renal/hepatic adjustments and all procedural timing locally.