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Objectives To prospectively evaluate a real-world pathway for routine reflux investigation using non-endoscopic capsule sponge (CS) triage with respect to impact on endoscopy, histology and long-term safety.Methods Patients with reflux symptoms received CS as part of a triage pathway in a UK hospital over 4 years. Only patients with abnormal CS, inadequate samples or ongoing symptoms had endoscopy. Clinical outcomes and patient evaluation were assessed.Results 871 patients had CS, 87.6% providing adequate samples. 540 (62%) did not require endoscopy and 82% were discharged. Patients with normal CS were significantly more likely to have minor findings/normal endoscopy (p<0.001). 86 (9.9%) had abnormal CS: 1 patient was diagnosed with oesophageal cancer, 2 with Barrett’s dysplasia and 34 with Barrett’s oesophagus (BO). Malignant/premalignant pathology and endoscopic yield of major findings were significantly increased in abnormal CS (p<0.001). The positive predictive value for histological BO in abnormal CS test was 43.5%, NPV 98.2%. Follow-up was 2078 patient years, median 27.24 months (range 12–48). Gastric cancer was diagnosed in one patient 2 weeks after normal CS due to concerning symptoms at appointment. Only six (1.8%) patients were found to have Barrett’s/atrophic gastritis in those with a negative CS who had endoscopy for persistent symptoms. 97.5% patients found CS acceptable and 94% would have another CS.Conclusion CS pathway is acceptable to patients, safely identifies pathology, augments the proportion of significant endoscopic diagnoses while ensuring appropriate endoscopy and discharge of low-risk patients. These findings could inform a patient-friendly and resource-efficient service for routine reflux and aid appropriate endoscopy utilisation.