What are the clinical features of Gastroesophageal Reflux Disease (GERD)?

Clinical Features of Gastroesophageal Reflux Disease (GERD)

GERD presents with a spectrum of clinical manifestations ranging from typical esophageal symptoms (heartburn and regurgitation) to extraesophageal problems (chronic cough, hoarseness) that may occur without any gastrointestinal complaints. 1

Typical Esophageal Symptoms

The classic presentation includes:

• Heartburn: A burning discomfort in the retrosternal area that moves upward toward the throat, occurring in approximately 89% of gastroenterology patients 1
• Acid regurgitation: The backflow of gastric contents into the esophagus or mouth 1
• Dysphagia: Difficulty swallowing, reported in population-based studies 1

These typical symptoms (heartburn and regurgitation) are approximately 70% sensitive and specific for objective GERD, providing the rationale for empiric proton pump inhibitor trials without prior testing 1

Extraesophageal and Atypical Manifestations

Silent GERD - A Critical Pitfall

GERD can be completely silent from a gastrointestinal standpoint in up to 75% of patients when it causes chronic cough, making diagnosis challenging 1. This represents a major clinical pitfall where providers may miss the diagnosis if they rely solely on the presence of heartburn or regurgitation 1.

Respiratory Manifestations

• Chronic cough: GERD accounts for 5-41% of chronic cough cases in adults, ranking as the second most common cause in recent studies 1
• Hoarseness: Present in 100% of otolaryngology patients with laryngopharyngeal reflux disease, yet only 6% report heartburn 1
• Recurrent pneumonia: Can occur as a complication in certain populations 1

Other Atypical Symptoms

• Non-cardiac chest pain: A recognized manifestation warranting empiric PPI trial 1
• Sore throat and laryngeal symptoms: Related to laryngopharyngeal reflux 1

Age-Specific Clinical Features

Infants (< 1 year)

• Regurgitation or "spitting up": Reported to occur daily in 50% of all infants as a normal physiologic process 1
• Vomiting: Forceful expulsion of gastric contents via coordinated motor response 1
• Feeding difficulties and irritability: Common troublesome symptoms 1

Children and Adolescents (> 1 year)

• Heartburn and regurgitation: Similar to adult presentation 1
• Epigastric pain: A key gastrointestinal feature 2
• Recurrent regurgitation: Distinguishes pathologic GERD from physiologic reflux 2

Important caveat: Do not use acid suppressive therapy solely for chronic cough in children ≤14 years without gastrointestinal symptoms such as recurrent regurgitation or heartburn 2

High-Risk Populations

Certain groups have significantly higher prevalence of severe GERD 1:

• Neurologic impairment: Highest risk group 1
• Obesity: Both a risk factor and potential consequence of GERD 1
• History of repaired esophageal atresia: Anatomic predisposition 1
• Chronic respiratory disorders: Including bronchopulmonary dysplasia, cystic fibrosis, and post-lung transplant 1
• Hiatal hernia: Mechanical etiology promoting reflux 1

Symptom Frequency and Patterns

• Occasional symptoms: Population studies show 59% prevalence of occasional GER-related symptoms 1
• Weekly symptoms: Reported by 20% of respondents in population-based studies 1
• Postprandial timing: Symptoms typically occur during meals and the postprandial state 1
• Nocturnal symptoms: Particularly in patients with hiatal hernia or after large meals 1

Distinguishing Physiologic Reflux from GERD

Gastroesophageal reflux (GER) is a normal physiologic process occurring up to 50 times daily in healthy individuals without producing symptoms, whereas GERD refers to disease manifested by troublesome symptoms and/or tissue damage 1. This distinction is crucial for avoiding overtreatment of normal physiologic reflux 1.

Complications Suggesting Advanced Disease

• Erosive esophagitis: Acid-related damage to esophageal lining requiring endoscopic diagnosis 3, 4
• Barrett's esophagus: Premalignant condition 1
• Peptic stricture: Causing progressive dysphagia 5
• Esophageal adenocarcinoma: Long-term complication 1
• Pulmonary disease: From chronic aspiration 1

Clinical Profile Predicting GERD as Cause of Symptoms

When evaluating patients with chronic cough or atypical symptoms, the clinical profile includes absence of smoking history, normal chest radiograph, absence of upper respiratory symptoms, and failure to respond to bronchodilators 1. These patients warrant empiric anti-reflux therapy even without gastrointestinal symptoms 1.