Clinical suspicion and diagnostic strategies in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic disorder characterized by the abnormal return of gastric contents into the esophagus, leading to bothersome symptoms and potential mucosal injury. Clinically, it presents mainly with heartburn, regurgitation, and chest pain, although extraesophageal manifestations such as chronic cough, asthma, laryngitis, and dental erosions may also occur. Other conditions – including pharyngitis, sinusitis, idiopathic pulmonary fibrosis, otitis media, sleep apnea, and burning mouth syndrome – have been attributed to reflux but lack conclusive causal evidence. GERD may cause erosive esophagitis, peptic stricture, or Barrett’s esophagus. Diagnosis is usually suspected based on typical recurrent symptoms that respond to empirical treatment with proton pump inhibitors (PPIs) or potassium-competitive acid blockers (P-CABs), though clinical response alone does not confirm an objective diagnosis. In patients with persistent or atypical symptoms, alarm features (dysphagia, weight loss, anemia), or when surgical or endoscopic therapy is being considered, additional evaluation is required. Upper endoscopy allows detection of reflux-related lesions such as esophagitis (Los Angeles grades B-D) or intestinal metaplasia. However, up to 70% of patients show normal endoscopic findings, which does not exclude GERD. Esophageal pH monitoring – with or without impedance – is the reference standard to quantify esophageal acid exposure and correlate reflux episodes with symptoms. It is particularly useful in refractory cases or when endoscopy is negative. Proper interpretation requires discontinuation of PPIs seven days prior to testing, except in patients with an established diagnosis, in whom pH monitoring is used to assess treatment refractoriness.