What is the first step in managing a GERD patient who presents with alarm symptoms?

In managing a patient with gastroesophageal reflux disease (GERD) who presents with alarm symptoms—such as dysphagia, unexplained weight loss, gastrointestinal bleeding, or persistent vomiting—the first step is to perform an upper endoscopy. Alarm symptoms indicate a potentially severe underlying condition, such as esophageal stricture, malignancy, or severe esophagitis, which warrants an immediate diagnostic approach. An upper endoscopy allows for direct visualization of the esophagus and gastric mucosa, enabling the clinician to assess for any abnormalities, obtain biopsies if necessary, and determine the most appropriate treatment plan based on the findings.

On the other hand, initiating proton pump inhibitor therapy, antacid treatment, or lifestyle modifications without first investigating the cause of alarm symptoms could delay critical diagnosis and treatment of serious conditions. Hence, while these options may be useful in the management of typical GERD without alarm features, they are not suitable as the initial approach when alarm symptoms are present.