The most common complaints in patients with GERD are heartburn; regurgitation; and, occasionally, dysphagia or difficult swallowing. These represent the so-called typical symptoms of GERD. Although none of these are specific to GERD, the latter is more commonly a sign of serious underlying pathology, including esophageal carcinoma. Dysphagia should always be investigated promptly and thoroughly.
Heartburn is characterized as a substernal burning discomfort often radiating from epigastrium to sternal notch. Occasionally patients will refer to it as chest pain rather than heartburn, and the two can be difficult to distinguish. Even the location can be variable with patients occasionally experiencing discomfort in the epigastrium, base of the neck, back, or other areas. Heartburn is typically made worse by spicy foods such as tomato sauce, citrus juices, chocolate, coffee, and alcohol. It occurs 1 to 2 hours after eating, often at night and is relieved by antacids and antisecretory agents such as the over-the-counter histamine-2 blockers. It is well recognized that the severity of symptoms is not necessarily related to the severity of the underlying disease.
Regurgitation is the spontaneous return of gastric contents proximal to the GE junction. Its spontaneous nature distinguishes it from vomiting. The patient often gets a sensation that fluid or food is returning into the esophagus, even if it does not reach as high as the pharynx or mouth. It is typically worse at night in the recumbent position or when lying down after a meal. Patients commonly compensate by not eating late at night or by sleeping partially upright with several pillows or in a chair. This symptom is often less well relieved with antacids and antisecretory agents, although it may change in character from acid to a more bland nature.
Dysphagia is present in up to 40% of patients with GERD. It is generally manifested by a sensation of food hanging up in the lower esophagus (esophageal dysphagia) rather than difficulty transferring the bolus from the mouth to the esophageal inlet (oropharyngeal dysphagia). Classically dysphagia limited to only solid food, with normal passage of liquids, suggests a mechanical disorder such as a large hernia, stricture, or tumor, whereas difficulty with both solids and liquids suggest a functional or motor disorder. It often develops slowly enough that the patient may adjust his or her eating habits and not necessarily notice that it is happening. Thus, a thorough esophageal history includes an assessment of the patient's dietary history. Questions should be asked regarding the consistency of food that is typically eaten; whether the patient requires liquids with the meal; is the last to finish; has interrupted a social meal; chokes or vomits with eating; or whether he or she has been admitted on an emergency basis for food impaction. These assessments, in addition to the ability to maintain nutrition, help to quantify the dysphagia and are important in determining the indications for surgical therapy.
Many patients with GE reflux often manifest atypical symptoms, such as cough, asthma, hoarseness, and noncardiac chest pain. Atypical symptoms are the primary complaint in 20% to 25% of patients with GERD and are secondarily present in association with heartburn and regurgitation in many more. It is considerably more difficult to prove a cause-and-effect relationship between atypical symptoms and GE reflux than it is to do so for the typical symptoms. Consequently, the results of surgical therapy have been correspondingly less good. That is not to say that patients with atypical symptoms are not good candidates for antireflux surgery, because many will benefit greatly, but that in these patients it should be applied cautiously. Often a trial of high-dose proton pump inhibitors (PPIs) is helpful. Given atypical symptoms, the outcome of antireflux surgery is optimal in patients with a good response to medical treatment rather than in those who fail to respond.
The diagnosis of GERD based on symptoms alone is correct in only approximately two thirds of patients.20 This is because these symptoms are not specific for GE reflux and can be caused by other diseases such as achalasia, diffuse spasm, esophageal carcinoma, pyloric stenosis, cholelithiasis, gastritis, gastric or duodenal ulcer, and coronary artery disease. This fact underscores the need for objective diagnosis before the decision is made for surgical treatment.