ALARM
GI Red Flag Symptoms
Any of these → endoscopy or imaging, not a PPI trial.
The board-friendly take on dyspepsia is that an empiric PPI is fine — until ALARM symptoms show up. Anemia, Loss of weight, Anorexia, Recent onset of progressive symptoms, and Melena/hematemesis or a Mass on exam push the patient past trial-of-therapy and into endoscopy or cross-sectional imaging. The AANP exam loves this branch point: a 55-year-old with epigastric pain and microcytic anemia is not a PPI candidate, they are a GI referral. Memorize the five letters and the implicit age cutoff (most guidelines flip to scope-first at age 55-60) and the question writes itself.
- AAge >50New-onset GI symptoms in older patients.
- LLoss of weightUnintentional weight loss.
- AAnemiaEspecially iron-deficiency — suggests occult bleed.
- RRectal bleeding / melenaAny visible blood in stool or black tarry stool.
- MMass or dysphagiaPalpable abdominal mass; swallowing difficulty; odynophagia.
Clinical Context
GI red flags that upgrade a complaint from "empiric PPI trial" to "refer for endoscopy or imaging." Especially important in GERD or dyspepsia workups where PPI is commonly first-line.
Standard teaching: test-and-treat for H. pylori in patients <50 without alarm features; scope anyone with alarm features regardless of age. AANP primary-care stems often describe a 55-year-old with new dyspepsia and unintentional weight loss — NOT a candidate for empiric PPI, refer for EGD.
Practice Questions
A 62-year-old male presents to the clinic with 3 months of worsening dyspepsia and epigastric burning. He reports 15 pounds of unintentional weight loss over the same period. Labs show hemoglobin 10.2 g/dL with low ferritin consistent with iron-deficiency anemia. He has not tried any acid suppression. Applying the ALARM red-flag framework, what is the most appropriate next step?
Sources
Ready to practice?
1,500+ AANP-style questions with rationales — free trial.