Because gastroesophageal reflux disease (GERD) diminishes quality of life and can cause long-term health complications, it is important to differentiate the disease from occasional common heartburn, diagnose it accurately and treat it appropriately. The most basic step toward this goal is to recognize GERD’s symptoms.
Some symptoms are common to most patients and easy to recognize, such as heartburn and regurgitation. However, GERD also has atypical symptoms that can occur simultaneously with classic symptoms or in cases where no classic symptoms are present. For patients with atypical symptoms alone, accurate diagnosis often takes a long, circuitous route. By understanding GERD’s atypical symptoms, physicians can diagnose the disease early and accurately and ensure patients get the treatment they need to prevent esophageal damage and relieve discomfort.
Atypical Symptoms of GERD
It is difficult to estimate how commonly patients experience atypical symptoms of GERD, especially because many of these symptoms overlap with other problems. For example, it is very common for people with or without GERD to experience hoarseness and secretions of the posterior pharynx in morning. A number of patients with traditional symptoms have this problem, but absent GERD’s classic symptoms, physicians may not immediately diagnose the problem as GERD.
The following atypical symptoms are shared with other problems, but they are commonly exhibited by patients with GERD.
- Chest pain with no clear cardiac origin: When patients complain of recurring chest pain that varies in intensity, a careful history and simple testing help us sort out if cardiac etiology is to blame. Because coronary artery disease is such a critical diagnosis, it should be excluded in all patients complaining of chest pain. This can be accomplished with a detailed history, noninvasive testing and, if indicated, referral to a cardiologist.
It is also important to note that women may report atypical chest pain symptoms that are due to cardiac disease more often then men. In addition, since both of these disorders occur commonly, one should always be suspicious that chest discomfort symptoms may be due to cardiac disease and have that cause excluded before assuming all the symptoms are from an atypical presentation of GERD.
- Pulmonary symptoms: GERD can cause a number of pulmonary symptoms, including chronic cough, frequent upper respiratory infections and chronic pulmonary damage as a result of the inhalation of acid and other gastric contents into the lungs. Occasionally, asthma-like symptoms include wheezing, chest tightness and difficulty breathing can be caused by GERD.
- Symptoms common to routine infections: Regurgitated stomach acid can inflame the throat and sinuses, resulting in symptoms of sinusitis, sore throat, chronic hoarseness and coughing. Patients may feel like they have a “lump in their throat,” a sensation that can occur due to inflammation of the larynx or hypopharynx, which can be caused by GERD.
Many complex GERD patients with atypical symptoms are referred to a gastroenterologist. When patients with atypical symptoms are referred to other specialists–a cardiologist for chest pain or an ENT for sinus symptoms, for example–those physicians usually determine that GERD is the problem and may start medical therapy or refer the patients to a gastroenterologist.
Objective Clinical Testing of GERD
Gastroenterologists often see complex cases of GERD, typically patients who have been using high-dose proton pump inhibitors (PPIs) without relief. We often start over, looking at patients’ detailed history, prior evaluation and response to medications.
Although the absence of classic symptoms creates greater uncertainty, we resolve that uncertainty with the same tests we use for a standard GERD diagnosis. We often start with a basic upper endoscopy to look for damage from acid exposure in the distal esophagus. This can be supplemented with pH testing by either wireless probe placement at the time of endoscopy or standard transnasal pH probe testing. Both tests are performed while the patient is off of all medications that would reduce acid secretion. Frequently, we add high-resolution manometry to the evaluation to document the functioning of the lower esophageal sphincter and esophageal peristalsis.
Adding these tests to the evaluation, history and conversation with patients, we can establish an objective diagnosis and characterization of GERD.
General practitioners should know that gastroenterologists have objective testing at our disposal, which is particularly helpful in cases with atypical symptoms where physicians are uncertain. In addition, even typical reflux patients whose symptoms respond to medications should have a diagnostic evaluation at some point, including endoscopy to make certain that esophageal damage such as Barrett’s esophagus is not present.
Treating Atypical Cases of GERD
Patients who differ symptomatically from classic GERD also may differ in their response to treatment. In my experience, many patients with atypical symptoms only respond to medications used long term at a high dose. Where a patient with classic symptoms might feel better in two to four weeks on a normal dose of PPIs, an atypical patient might require three to six months on high-dose PPIs to feel relief. Sometimes these patients do not show improvement on medications, so we need to control reflux another way.
Typically, if we can document GERD physiology with testing and the patient has had persistent atypical symptoms, we consider surgical approaches to GERD. These include the standard Nissen fundoplication, surgical variants of that operation and magnetic sphincter augmentation. While these options are available at many centers that treat GERD, they do involve a surgical approach and all have associated side effects, benefits and risks.
Today, we also have safe, nonsurgical options for GERD. This is welcome news not only for patients, but also for primary care physicians who bear the brunt of patients who have had a Nissen fundoplication and then developed side effects, including gas bloat, difficulty belching, flatulence and occasionally the return of GERD symptoms if the surgery is not effective.
Endoscopic treatment options are not as aggressive in their effects on the lower esophageal sphincter, so patients do not typically report the side effects seen after surgery in the great majority of cases. While the treatment effect may be less than what is seen with surgery, the lack of persistent long-term side effects makes these options a reasonable alternative for patients and physicians to consider.
Endoscopic procedures are performed transorally without incisions, on an outpatient basis. Mechanical options such as the TIF procedure with the EsophyX device attempt to mimic a Nissen by performing a partial wrap of the stomach around the lower esophagus, with less post-procedure side effects than a fundoplication. An endoscopic treatment that does not involve altering the anatomy is the Stretta procedure. Stretta applies low levels of radiofrequency energy to the lower esophageal sphincter muscle, causing changes that increase muscle thickness and reduce symptoms of GERD safely and effectively long-term. With an increased barrier at the lower esophageal sphincter zone, less acid reaches the upper esophagus and esophageal erosions are permitted to heal. This modality also can improve pain symptoms, including the atypical chest pain seen in GERD, which more invasive options may not address.
More research is needed to determine the incidence of atypical symptoms and the best treatment choices for these patients. In my own experience, once we recognize that GERD’s symptoms go well beyond simple heartburn, we can identify the disease and provide relief for our patients’ challenging symptoms.
Readings & Resources (click to view)
Stefanidis G, Viazis N, Kotsikoros N, et al. Long-term benefit of transoral incisionless fundoplication using the EsophyX device for the management of gastroesophageal reflux disease responsive to medical therapy. Dis Esophagus. 2016 Nov 21. doi: 10.1111/dote.12525
Brar TS, Draganov PV, Yang D. Endoluminal Therapy for Gastroesophageal Reflux Disease: In Between the Pill and the Knife? Dig Dis Sci. 2017 Jan;62(1):16-25. doi: 10.1007/s10620-016-4355-3
Trad KS, Fox MA, Simoni G, et al. Transoral fundoplication offers durable symptom control for chronic GERD: 3-year report from the TEMPO randomized trial with a crossover arm. Surg Endosc. 2016 Sep 21. doi: 10.1007/s00464-016-5252-8
Fass, R, Cahn, F, Scotti, DJ, Gregory DA. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc 2017. Available online 23 February 2017. doi:10.1007/s00464-017-5431-2
Dughera L, Navino M, Cassolino P, et al. Long-term results of radiofrequency energy delivery for the treatment of GERD: Results of a 48-month prospective study. Diagn Ther Endosc. 2011;2011:507157. doi: 10.1155/2011/507157
Noar MD, Lotfi-Emran S. Sustained improvement in symptoms of GERD and antisecretory drug use: 4-year follow-up of the Stretta procedure. Gastrointest Endosc. 2007 Mar;65(3):367-72. doi: 10.1016/j.gie.2006.11.015
Dughera L, Rotondano G, De Cento M, Cassolino P, Cisarò F. Durability of Stretta Radiofrequency Treatment for GERD: Results of an 8-Year Follow-Up. Gastroenterol Res Pract. 2014;2014:531907. doi: 10.1155/2014/531907