Reflux symptoms (heartburn and regurgitation) can be caused by altered physiology, altered perception, or a mixture of both. Current management algorithms for uninvestigated symptoms are not tailored to make this distinction.

A detailed clinical history can help identify patients with acid-related or functional pathophysiology (visceral hypersensitivity or central nervous system dysregulation).

Endoscopy, in the absence of alarm symptoms, is not likely to reveal organic disease or alter management.

Responsiveness to a short course of proton pump inhibitors (PPIs) is not a reliable diagnostic tool for gastro-oesophageal reflux disease (GORD) but can be used with the clinical history to help direct long- term management and non-pharmacological interventions.

Patients with suspected functional syndromes not responding to standard-dose PPI should be managed with a combination of non-PPI approaches, such as lifestyle modifications, neuromodulators, mucosal protection, reassurance, and psychological support.