Can gastroesophageal reflux disease (GERD) cause left arm pain?

GERD Can Cause Left Arm Pain as Part of Reflux Chest Pain Syndrome

GERD can cause left arm pain, particularly when it manifests as reflux chest pain syndrome, which occurs in approximately 30% of patients with recurrent non-cardiac chest pain. 1 This pain can radiate to the left arm, mimicking cardiac symptoms, which is why cardiac causes must always be ruled out first.

Differentiating GERD-Related Arm Pain from Cardiac Causes

When evaluating left arm pain that might be related to GERD, it's critical to follow this approach:

1. Rule out cardiac causes first

   • Cardiac chest pain with radiation to the left arm represents a potentially life-threatening condition
   • The American Heart Association guidelines emphasize that ischemic heart disease must be thoroughly considered before accepting a diagnosis of reflux chest pain syndrome 1
   • Cardiac evaluation may include ECG, cardiac biomarkers, and risk stratification tools

2. Consider GERD as a cause only after cardiac etiology is excluded

   • GERD-related chest pain can be indistinguishable from ischemic cardiac pain 1
   • Pain may radiate to the left arm, jaw, back, or other areas similar to cardiac pain

Diagnostic Approach for Suspected GERD-Related Arm Pain

After cardiac causes have been excluded:

1. Evaluate for concurrent typical GERD symptoms

   • Heartburn
   • Regurgitation
   • Dysphagia (difficulty swallowing)

2. Consider empiric PPI trial

   • The American Gastroenterological Association strongly recommends twice-daily PPI therapy as an empirical trial for patients with suspected reflux chest pain syndrome 1
   • A positive response to a 4-week trial of twice-daily PPI therapy supports GERD as the cause

3. Further testing if symptoms persist

   • Esophageal manometry and pH monitoring may be needed if symptoms continue despite PPI therapy 1
   • Upper endoscopy is indicated for patients with persistent GERD symptoms despite 4-8 weeks of twice-daily PPI therapy 2

Treatment of GERD-Related Arm Pain

When GERD is confirmed as the cause of left arm pain:

• First-line treatment: Proton pump inhibitors (PPIs) are the most effective control of gastric acidity and the medical treatment of choice 3
• Dosing: Twice-daily PPI therapy is recommended for reflux chest pain syndrome 1
• Duration: Initial treatment for 4 weeks, with continuation based on response
• Treatment failure: If symptoms persist despite 4-8 weeks of twice-daily PPI therapy, further diagnostic evaluation is warranted 2

Important Clinical Considerations

• Non-response to PPI: Should raise suspicion that the diagnosis is not GERD 3
• Chronic symptoms: Occurrence of reflux symptoms for more than six months is a confirmatory feature of GERD 1
• Alarm symptoms: Presence of dysphagia, gastrointestinal bleeding, unexplained weight loss, or recurrent vomiting warrants prompt endoscopic evaluation 2

Pitfalls to Avoid

1. Premature attribution to GERD: Never assume left arm pain is due to GERD without first excluding cardiac causes, as this could lead to missed diagnosis of life-threatening conditions
2. Inadequate PPI trial: Using insufficient dosing or duration of PPI therapy may lead to false-negative results
3. Missing alarm symptoms: Failing to recognize warning signs that require endoscopic evaluation
4. Overlooking refractory cases: Some patients with GERD may not respond to standard PPI therapy and require additional diagnostic evaluation or treatment approaches

GERD-related left arm pain is a diagnosis of exclusion that should only be considered after cardiac causes have been thoroughly evaluated. When properly diagnosed and treated, most patients experience significant symptom improvement with appropriate acid suppression therapy.