What are the symptoms and treatment options for Gastroesophageal Reflux Disease (GERD) in adults?

Symptoms of Gastroesophageal Reflux Disease (GERD)

GERD presents with heartburn and regurgitation as the typical esophageal symptoms, while non-cardiac chest pain represents an atypical esophageal symptom, and extra-esophageal manifestations include chronic cough, dysphonia, sore throat, and globus. 1

Typical Esophageal Symptoms

The hallmark symptoms of GERD are:

• Heartburn: The most characteristic symptom, occurring at least once weekly in affected patients 2
• Regurgitation: Return of gastric contents into the oropharynx 3, 4

These symptoms affect more than 30% of United States adults on at least a weekly basis 1. The prevalence in Western societies reaches approximately 30%, making GERD one of the most commonly encountered disorders in primary care 4.

Atypical Esophageal Symptoms

• Non-cardiac chest pain: A recognized atypical presentation that requires differentiation from cardiac causes 1

Extra-Esophageal Manifestations

GERD can present with symptoms outside the esophagus, though these are less specific and more challenging to diagnose:

• Chronic cough: A common extra-esophageal symptom 1
• Dysphonia (hoarseness): Voice changes related to laryngeal irritation 1, 5
• Sore throat: Pharyngeal irritation from refluxed contents 1
• Globus sensation: Feeling of a lump in the throat 1
• Otitis media: Ear infections in some patients 5
• Dental enamel erosion: Atypical loss from chronic acid exposure 5
• Respiratory symptoms: Including asthma exacerbations, chronic bronchitis, recurrent pneumonia, and idiopathic pulmonary fibrosis 5

Important Clinical Distinctions

Patients with isolated extra-esophageal symptoms require upfront objective reflux testing off medication rather than an empiric PPI trial, as these symptoms are less specific for GERD. 1, 6

Alarm Symptoms Requiring Immediate Endoscopy

The following symptoms indicate need for urgent evaluation rather than empiric treatment:

• Dysphagia: Difficulty swallowing 7, 8
• Odynophagia: Painful swallowing 8
• Unintentional weight loss 7, 8
• Gastrointestinal bleeding or anemia 7, 8

Treatment Approach Based on Symptoms

For Typical Symptoms Without Alarm Features

Patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms should receive a 4- to 8-week trial of single-dose PPI therapy. 1, 7

• If inadequate response occurs, increase to twice-daily dosing or switch to a more effective acid suppressive agent 1, 7
• With adequate response, taper PPI to the lowest effective dose 1, 7
• Clinicians should emphasize the safety of PPIs for GERD treatment 1

For PPI Non-Responders

If symptoms persist after 4-8 weeks of PPI therapy:

• Perform upper endoscopy with complete evaluation including Hill grading of the gastroesophageal flap valve, assessment for erosive esophagitis (Los Angeles classification), hiatal hernia measurement, and Barrett's esophagus screening 1, 8
• If no erosive disease (Los Angeles B or greater) or long-segment Barrett's esophagus (≥3cm) is found, perform prolonged wireless pH monitoring off PPI therapy (96-hour preferred) 1

Adjunctive Symptom-Specific Therapies

Personalize adjunctive pharmacotherapy to the specific GERD phenotype rather than using empiric combinations: 1

• Alginate antacids: For breakthrough symptoms 1
• Nighttime H2 receptor antagonists: For nocturnal symptoms 1
• Baclofen: For regurgitation or belch-predominant symptoms 1
• Prokinetics: For coexistent gastroparesis 1

Lifestyle and Dietary Modifications

Provide standardized education on:

• Weight management: Excessive body weight, particularly obesity, contributes to GERD symptoms 1, 2
• Dietary triggers to avoid: Fatty, fried, sour, spicy foods, orange and grapefruit juice, tomatoes, chocolate, coffee/tea, carbonated beverages, and alcohol 2
• Eating habits: Avoid large meal volumes, irregular meal patterns, and eating just before bedtime 2
• Alcohol and smoking cessation: Moderate/high alcohol consumption and smoking are modifiable risk factors 2
• Physical activity patterns: Avoid postprandial and vigorous physical activity while maintaining regular moderate exercise 2

Common Pitfalls to Avoid

• Do not assume all chest pain is GERD: Non-cardiac chest pain requires cardiac evaluation first before attributing to reflux 1
• Do not give empiric PPI trials for isolated extra-esophageal symptoms: These require objective testing upfront as they are poorly responsive to acid suppression 1, 6
• Do not continue long-term PPI without objective confirmation: If PPI therapy continues beyond 12 months in unproven GERD, evaluate appropriateness and offer endoscopy with prolonged wireless reflux monitoring off PPI 1
• Do not miss functional esophageal disorders: Patients without erosive disease on endoscopy and with physiologic acid exposure often have functional disorders requiring neuromodulation or behavioral interventions rather than continued acid suppression 1