Physical Examination Findings in GERD
The physical examination in GERD is typically normal, and its primary purpose is to exclude alternative diagnoses and identify warning signs ("red flags") that suggest more serious pathology requiring urgent investigation. 1, 2
Key Components of the Physical Exam
General Inspection and Vital Signs
- Assess for fever, which suggests infection or inflammatory complications rather than uncomplicated GERD 1, 2
- Evaluate nutritional status and document weight, as poor weight gain (especially in infants) or unintentional weight loss (in adults) are warning signs requiring further investigation 1, 2
Abdominal Examination
- Palpate for abdominal tenderness or distension, which are concerning findings that suggest alternative diagnoses such as peptic ulcer disease, gastric outlet obstruction, or malrotation 1, 2
- Assess for hepatosplenomegaly, which is a warning sign requiring further workup 1, 2
- Evaluate for epigastric tenderness, though this is nonspecific and does not confirm or exclude GERD 1
Pediatric-Specific Examination Elements
- Examine the fontanelle in infants for bulging, which indicates increased intracranial pressure and requires urgent evaluation 1, 2
- Measure head circumference to detect macro- or microcephaly, both warning signs for genetic/metabolic syndromes 1, 2
- Assess for signs of seizure activity or neurologic abnormalities 1, 2
Examination for Complications and Associated Conditions
- Inspect the oropharynx for dental erosions, which may indicate chronic acid exposure 3, 4
- Auscultate lungs for wheezing or crackles, as respiratory symptoms (coughing, choking, wheezing) can be associated with GERD, though these are nonspecific 2, 5
Critical Warning Signs ("Red Flags") on Physical Exam
The following findings mandate immediate further investigation and are NOT consistent with uncomplicated GERD: 1, 2
- Signs of gastrointestinal bleeding (pallor, tachycardia, hypotension) 1, 2
- Lethargy or altered mental status 1, 2
- Hepatosplenomegaly 1, 2
- Abdominal mass or significant distension 1, 2
- Bulging fontanelle in infants 1, 2
- Macro- or microcephaly 1, 2
- Documented or suspected genetic/metabolic syndrome features 1, 2
Clinical Pitfalls to Avoid
- Do not rely on physical examination alone to diagnose GERD, as the exam is typically normal in uncomplicated cases 1, 3
- Do not dismiss warning signs even if typical GERD symptoms are present—these require endoscopy and further investigation regardless of symptom profile 1, 3
- In infants with persistent forceful vomiting, perform pyloric ultrasonography first to evaluate for pyloric stenosis before considering upper GI series 1, 2
- Do not assume respiratory symptoms are due to GERD without ruling out primary pulmonary pathology 1
When Physical Exam Findings Should Trigger Diagnostic Testing
Proceed directly to endoscopy (rather than empiric PPI trial) if any of the following are present on physical examination: 1, 3