Symptoms of Gastroesophageal Reflux Disease (GERD)
Typical Esophageal Symptoms
The hallmark symptoms of GERD are heartburn (retrosternal burning rising toward the throat) and acid regurgitation, which occur at least weekly and are approximately 70% sensitive and specific for objective GERD. 1, 2
- Heartburn is the most characteristic symptom, described as a retrosternal burning sensation that rises toward the throat 1
- Regurgitation involves the effortless return of gastric contents into the mouth or throat, and is present in approximately 72.6% of GERD patients 1
- Dysphagia (difficulty swallowing) can occur, particularly in patients with complications like strictures or severe esophagitis 1
- Non-cardiac chest pain represents an atypical esophageal symptom that can mimic cardiac disease 1
Extraesophageal Symptoms
Extraesophageal manifestations include chronic cough, dysphonia (hoarseness), sore throat, and globus sensation, though these symptoms have lower specificity for GERD and require more intensive evaluation. 1
- Chronic cough occurs in 0-41% of GERD cases referred to specialty clinics, and GERD may be "silent" from a GI perspective in up to 75% of patients with cough 1
- Laryngitis and hoarseness result from reflux affecting the larynx 1, 3
- Globus sensation (feeling of a lump in the throat) and constant throat clearing 4
- Dental erosions from chronic acid exposure 3, 4
- Asthma exacerbations and recurrent pneumonia in some patients 1, 3
- Otitis media and chronic sinusitis have been associated with reflux 3, 4
Age-Specific Presentations
Infants (Under 1 Year)
In infants, GERD presents with regurgitation or vomiting associated with irritability, feeding refusal, poor weight gain, and back arching during feedings, with peak incidence at 4 months of age affecting approximately 50% of infants. 1
- Irritability and crying during or after feeds 1
- Anorexia or feeding refusal 1
- Poor weight gain or failure to thrive 1
- Dysphagia with presumably painful swallowing 1
- Back arching during feedings 1
Children and Adolescents
Adolescents typically present with adult-like symptoms of heartburn, while younger children may have more varied presentations including respiratory symptoms. 1
- Heartburn becomes more prominent in adolescents, similar to adult presentation 1
- Chronic cough and recurrent pneumonia 1
- Hoarseness and sore throat 1
- Bad breath (halitosis) 5
Associated Symptoms
Additional symptoms that may accompany GERD include epigastric pain (50%), retrosternal pain (47.1%), retrosternal tightness (33.2%), and nausea (36.5%), which respond variably to therapy. 1
Warning Signs Requiring Urgent Evaluation
Alarm features that suggest complications or alternative diagnoses include dysphagia, weight loss, gastrointestinal bleeding (hematemesis or hematochezia), persistent vomiting, and anemia. 1
- Dysphagia with weight loss suggests possible malignancy or stricture 1
- Gastrointestinal bleeding (hematemesis or melena) 1
- Persistent forceful vomiting, especially if bilious 1
- Unexplained weight loss 1
- Epigastric mass on examination 1
- Anemia 1
Treatment Overview
Proton pump inhibitors (PPIs) are the most effective first-line pharmacological treatment for GERD, superior to H2-receptor antagonists and placebo for both healing esophagitis and achieving symptomatic relief. 2, 6, 7
Initial Management
- Start with once-daily PPI therapy (e.g., omeprazole 20mg or lansoprazole 30mg daily) taken 30-60 minutes before breakfast 2, 6, 7
- Empiric PPI therapy is appropriate for patients with typical symptoms without need for initial endoscopy 1, 2
- Lifestyle modifications including head of bed elevation (6-8 inches) for nighttime symptoms, avoiding lying down 2-3 hours after meals, and weight loss for overweight/obese patients 1, 2
- Avoid trigger foods on an individualized basis (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes, fatty foods) 2, 8
Treatment Escalation
- If symptoms persist after 4-8 weeks of once-daily PPI, increase to twice-daily dosing (before breakfast and dinner) 1, 2
- For extraesophageal symptoms like chronic cough, twice-daily PPI for 8-12 weeks minimum is required, though response rates are lower than for typical symptoms 1, 2
- Consider adjunctive therapy based on symptom phenotype: alginate antacids for breakthrough symptoms, nighttime H2-receptor antagonists for nocturnal symptoms, or baclofen for regurgitation-predominant symptoms 1
Refractory Cases
- After failed empiric therapy with twice-daily PPI for 8 weeks, perform endoscopy to assess for esophagitis, Barrett's esophagus, eosinophilic esophagitis, or alternative diagnoses 1, 2
- Consider ambulatory 24-hour pH-impedance monitoring to confirm GERD diagnosis and determine mechanism of persistent symptoms 1
- Antireflux surgery (laparoscopic fundoplication or magnetic sphincter augmentation) is effective in carefully selected patients with proven GERD who have failed at least 3 months of intensive medical therapy 1, 2
Common Pitfalls
Do not assume GERD has been ruled out simply because empiric PPI therapy failed—the therapy may not have been intensive enough, or the patient may have non-acid reflux requiring additional interventions. 1
- Monitoring only heartburn risks missing improvement or worsening of other symptoms like regurgitation, which may respond differently to therapy 1
- In patients with dysphagia, obtain at least 5 esophageal mucosal biopsies during endoscopy to evaluate for eosinophilic esophagitis 1
- Extraesophageal symptoms require longer treatment duration (8-12 weeks of twice-daily PPI) and have lower response rates than typical GERD symptoms 1, 2
- Avoid metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile including risk of tardive dyskinesia 1, 2