What are the symptoms of Gastroesophageal Reflux Disease (GERD)?

Symptoms of Gastroesophageal Reflux Disease (GERD)

The two most specific symptoms of GERD are heartburn (retrosternal burning rising toward the throat) and acid regurgitation, which should both be routinely assessed in clinical practice. 1

Typical Esophageal Symptoms

Primary Symptoms

• Heartburn: A burning discomfort in the retrosternal area that moves upward toward the throat, best described using a "word picture" as "retrosternal burning rising towards the throat" to standardize patient understanding 1
• Regurgitation: The effortless return of gastric contents into the esophagus and mouth, which occurs independently of heartburn in some patients and should always be evaluated separately 1, 2
• Dysphagia: Difficulty swallowing that may indicate complications or coexistent conditions, considered an alarm symptom requiring endoscopic evaluation 1, 2

Secondary Esophageal Symptoms

• Epigastric pain: Present in 50-66% of patients with heartburn, though it overlaps significantly with other conditions 1
• Retrosternal pain: Occurs in approximately 47% of patients with GERD 1
• Retrosternal tightness: Reported in about 33% of patients 1
• Nausea: Present in approximately 37% of GERD patients 1

Extraesophageal and Atypical Manifestations

Respiratory Symptoms

• Chronic cough: GERD can cause chronic cough in 5-41% of cases, and critically, up to 75% of patients with GERD-related chronic cough have no gastrointestinal symptoms whatsoever (silent reflux) 1
• Hoarseness: May be the sole presenting symptom, particularly in otolaryngology patients where it can occur without any heartburn 1
• Wheezing and respiratory symptoms: Particularly common in infants and children 3, 4

Pediatric-Specific Presentations

Infants (<12 months):

• Regurgitation or vomiting 3
• Irritability and feeding refusal 3, 4
• Poor weight gain 3, 4
• Sleep disturbance 3
• Coughing, choking, or wheezing 3

Children (1-11 years):

• Abdominal pain 3
• Recurrent vomiting 3
• Feeding difficulties 3

Adolescents:

• Adult-like symptoms with predominant heartburn and regurgitation 3

Critical Clinical Considerations

Symptom Assessment Requirements

• Both frequency AND severity of heartburn must be measured, as they vary independently and more than one episode of mild heartburn per week is unacceptable to patients 1
• Monitoring heartburn alone risks missing improvement or worsening of other reflux symptoms, as different symptoms respond differently to therapy 1

Warning Signs Requiring Immediate Investigation

The following symptoms indicate serious underlying conditions beyond simple GERD and require urgent endoscopy 3, 4:

• Bilious or consistently forceful/projectile vomiting
• Gastrointestinal bleeding
• Abdominal tenderness or distension
• Weight loss
• Fever with gastrointestinal symptoms
• Dysphagia (in adults, suggests possible malignancy or stricture) 2, 5

Common Diagnostic Pitfalls

• Silent GERD: The absence of typical GI symptoms does NOT exclude GERD, particularly in patients with chronic cough, hoarseness, or other extraesophageal manifestations 1
• Symptom overlap: Substantial overlap exists between GERD symptoms and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, making diagnosis challenging 2
• Patient difficulty identifying predominant symptoms: When heartburn and epigastric pain coexist (which occurs in 63-75% of cases), 19% of patients cannot select their predominant symptom 1

Stress and Psychological Factors

• Stress and anxiety can trigger and worsen GERD symptoms through the brain-gut axis, and chronic stress can increase perception of reflux symptoms even without changes in actual acid exposure 6
• PTSD and anxiety may contribute to behavioral disorders including rumination and supragastric belching, which worsen GERD symptoms 6