Heartburn Symptoms and Initial Management
The typical symptoms of gastroesophageal reflux disease are retrosternal burning rising toward the throat (heartburn) and acid regurgitation, with initial management consisting of as-needed antacids or low-dose H2-receptor antagonists for occasional symptoms, and once-daily proton pump inhibitor therapy for frequent symptoms occurring more than 2-3 times weekly. 1, 2
Primary Symptoms to Assess
Heartburn is the most characteristic and specific symptom, described as retrosternal burning rising toward the throat. 3, 4, 5 Both frequency and severity must be evaluated, as they vary independently in individual patients and more than one episode of mild heartburn per week is unacceptable to most patients. 3
Acid regurgitation should be routinely evaluated in all patients, as it occurs in 72.6% of GERD patients but does not necessarily correlate with heartburn severity. 3 Moderate or severe regurgitation can be present in 5% of primary care patients and 16% of specialist patients even with no or mild heartburn. 3
Additional Symptoms to Monitor
Beyond heartburn and regurgitation, patients may experience:
- Epigastric pain (50.0% prevalence) 3
- Retrosternal pain (47.1% prevalence) 3
- Retrosternal tightness (33.2% prevalence) 3
- Nausea (36.5% prevalence) 3
- Dysphagia, which correlates with absence of heartburn 3
These symptoms respond differently to therapy and monitoring heartburn alone risks missing improvement or worsening of other reflux-attributable symptoms. 3
Initial Management Algorithm
For Occasional Symptoms (Less than 2-3 times weekly):
Start with as-needed antacids or low-dose H2-receptor antagonists (ranitidine 75 mg or famotidine 10-20 mg). 1, 2 Antacids provide relief within minutes with 80-90% response rates, while H2RAs provide relief within 30-60 minutes lasting up to 12 hours with a number needed to treat of 2-3. 1, 2
For Frequent Symptoms (More than 2-3 times weekly):
Initiate once-daily proton pump inhibitor therapy (omeprazole 20 mg or lansoprazole 15 mg) taken 30-60 minutes before meals, not at bedtime or with meals. 1, 2 This timing is critical, as failure to optimize PPI timing reduces efficacy by 30-50%. 1
Essential Lifestyle Modifications
Weight loss is strongly recommended for all overweight or obese patients, with dose-dependent benefits and significant symptom reduction. 1, 2 This has Grade B evidence strength. 1, 2
Elevate the head of the bed by 6-8 inches specifically for patients with nighttime heartburn or regurgitation, reducing symptom severity by 50-70%. 1, 2
Avoid lying down for 2-3 hours after meals, which reduces esophageal acid exposure by 30-50%. 1, 2
Identify and avoid specific food triggers only if they consistently provoke symptoms, such as coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks, and spicy foods. 2, 6
Management of Persistent Symptoms
If symptoms persist on once-daily PPI:
- Increase to twice-daily PPI dosing, providing additional relief in 50-70% of patients 1
- Add alginate-containing antacids for breakthrough symptoms, effective in 30-50% of patients 1
- Consider adding bedtime H2RA for nocturnal symptoms, providing relief in 40-60% of patients, though tachyphylaxis limits long-term use 1
Critical Pitfalls to Avoid
Do not assume GERD is ruled out after failed empiric therapy without objective testing, as this leads to misdiagnosis in 20-40% of patients. 1 Many patients require endoscopy or pH monitoring for accurate diagnosis. 1
Never use metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile with a number needed to harm of 5-10. 1
Regularly evaluate the need for continued PPI therapy rather than continuing long-term without periodic reassessment due to potential long-term risks. 1
Special Considerations for Extraesophageal Symptoms
Chronic cough, hoarseness, and asthma are less likely to respond to PPI therapy, with only 20-40% response rates. 3, 1 These patients require twice-daily PPI for 8-12 weeks minimum, and investigation of non-GERD causes is recommended before extensive testing if PPI therapy fails. 1