Diagnosis and Management of Gastroesophageal Reflux Disease (GERD)

Introduction to GERD Symptoms

The American Gastroenterological Association suggests that tasting acid in the throat (acid regurgitation) is a classic symptom of GERD and strongly suggests the diagnosis, particularly when accompanied by heartburn 1, 2
Acid regurgitation—the sensation of tasting acid or bitter material in the throat or mouth—is one of the two cardinal symptoms of GERD, alongside heartburn, and directly indicates that gastric contents are reaching the upper esophagus and pharynx 1, 2

Patients with heartburn and/or acid regurgitation should undergo a therapeutic trial of a PPI as the initial diagnostic approach, rather than immediate objective testing, according to the European Society of Gastrointestinal Endoscopy 2
A proper therapeutic trial consists of twice-daily full-dose PPI for 4 weeks, and the trial is considered positive if there is at least a 75% reduction in symptom frequency 2
If symptoms respond well to PPI therapy and the patient does not plan to undergo antireflux surgery, reflux monitoring with pH or pH/impedance testing is not recommended by the American College of Gastroenterology 2

Objective testing should be pursued in specific scenarios, including before antireflux surgery, even with typical symptoms responsive to PPIs, as indicated by the Society of American Gastrointestinal and Endoscopic Surgeons 2
Wireless pH monitoring is preferred when available, as it assesses acid exposure over 96 hours and has better patient tolerance, according to the American Gastroenterological Association 1
Normal acid exposure time (<4.0%) on all 4 days has an odds ratio of 10.0 for predicting successful PPI withdrawal 1

Acid exposure time (AET) >4.0% on at least 1 day of wireless pH monitoring indicates elevated acid burden, as defined by the American College of Gastroenterology 1
Los Angeles B or greater esophagitis and/or ≥2 days with AET >6% support a definitive GERD diagnosis, according to the European Society of Gastrointestinal Endoscopy 1
Symptom association measures (symptom association probability >95% and symptom index >50%) increase confidence that symptoms are truly reflux-related when AET is elevated 1

Delayed gastric emptying may contribute to GERD and should be considered when planning treatment, as failure to address risk factors may impact treatment success, as noted by the American Thoracic Society 3