History and exam

Key diagnostic factors

common

presence of risk factors

Strong risk factors include family history of heartburn or GORD; obesity; older age; or hiatus hernia.

heartburn

Burning sensation in the chest after meals is typical.

Can be worse after the patient has been lying down or bending over.

Can occur at night, but is not usually exertional.

acid regurgitation

Reflux of acid into the mouth, with a sour or bitter taste, mainly after meals.

Other diagnostic factors

uncommon

dysphagia

Causes of dysphagia such as a motility disorder, stricture, ring, or malignancy should be excluded with endoscopy.​[1]​

bloating/early satiety

Other causes should be ruled out (e.g., cancer or stricture).

laryngitis

Is associated with GORD based on population-based studies. However, extra-oesophageal syndromes are non-specific and usually multi-factorial in origin.[3]

ENT referral may be required, but positive laryngoscopy findings alone do not establish a causal connection to GORD.​[1]​

globus

Patients may describe a lump in the throat that is present despite swallowing.​[1]​

enamel erosion

Reflux of acid may cause enamel erosion of teeth.

halitosis

Has been found to be more common in people with GORD.[44] Patient may not be aware.

dyspepsia

Dyspepsia is significantly more common in patients with GORD symptoms than in those without them. Furthermore, symptoms of dyspepsia and GORD overlap in 25% of patients.[45]

Risk factors

strong

family history of heartburn or GORD

Immediate family history of heartburn or GORD: 2-3 times more likely to have symptoms.[27]

GORD is more common in monozygotic than dizygotic twins.[19]

older age

The risk of GORD increases with age.[16]

hiatus hernia

Anatomical changes associated with hiatus hernia may facilitate reflux by reducing competence of the gastro-oesophageal junction and inhibiting clearance of oesophageal acid post-reflux.[28][29]

obesity

Considered a risk factor for GORD.[16][17][18] Relative risks for symptoms of GORD were 1.43 for a BMI 25-30 kg/m² and 1.94 for a BMI >30 kg/m² in one meta-analysis.[17]

weak

use of lower oesophageal sphincter (LOS) tone-reducing drugs

Smooth muscle relaxants and anticholinergics reduce LOS tone through direct smooth muscle and neural mechanisms, facilitating reflux of stomach contents. Such drugs include nitrates, calcium-channel blockers, alpha- and beta-adrenergic agonists, theophylline, and anticholinergics.

psychological stress

A higher score on a psychosomatic symptom checklist has been associated with a higher risk of having symptoms.[27]

asthma

GORD symptoms are approximately twice as common in patients who have asthma compared with controls.[30]

While asymptomatic gastro-oesophageal reflux is common among patients with poorly controlled asthma, treatment with proton-pump inhibitors has not been shown to improve asthma control.[25]

use of non-steroidal anti-inflammatory drugs (NSAIDs)

May contribute to oesophagitis and strictures in patients with GORD. One meta-analysis reported a modest association between NSAID use (including aspirin) and prevalence of symptoms of GORD (OR 1.44, 95% CI 1.10 to 1.88).[16]

smoking

Pooled prevalence of gastro-oesophageal reflux symptoms was higher in current smokers than in non-smokers (19.6% vs. 15.9%, respectively; OR 1.26, 95% CI 1.04 to 1.52) in one meta-analysis.[16]

alcohol consumption

Meta-analyses do not consistently demonstrate increased risk of GORD among those who drink alcohol.[31][32]

per-oral endoscopic myotomy (POEM)

In one meta-analysis of patients undergoing treatment for achalasia, the pooled rates of GORD symptoms following POEM or laparoscopic Heller myotomy were 19% and 9%, respectively.[33]

dietary factors

Candidates include caffeinated foods or drinks, carbonated drinks, chocolate, citrus, and spicy foods.[34]

Evidence is limited. A Swedish study found no association with any of the above or with size of food portion.[35]

pregnancy

The prevalence of GORD symptoms is up to five times higher in pregnant women, compared with non-pregnant women.[11]

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