The symptoms of uncomplicated GERD are primarily heartburn, regurgitation, and nausea. Other symptoms occur when there are complications of GERD and will be discussed with the complications.

Heartburn

When acid refluxes back into the esophagus in patients with GERD, nerve fibers in the esophagus are stimulated. This nerve stimulation results most commonly in heartburn, the pain that is characteristic of GERD. Heartburn usually is described as a burning pain in the middle of the chest. It may start high in the abdomen or may extend up into the neck. In some patients, however, the pain may be sharp or pressure-like, rather than burning. Such pain can mimic heart pain (angina). In other patients, the pain may extend to the back. Since acid reflux is more common after meals, heartburn is more common after meals. Heartburn is also more common when individuals lie down because without the effects of gravity, reflux occurs more easily, and acid is returned to the stomach more slowly.

Episodes of heartburn may occur infrequently or frequently, but episodes tend to happen periodically. This means that the episodes are more frequent or severe for a period of several weeks or months, and then they become less frequent or severe or even absent for several weeks or months. Nevertheless, heartburn is a life-long problem, and it almost always returns.

Regurgitation

Regurgitation is the appearance of refluxed liquid in the mouth. In GERD, usually only small quantities of liquid reach the esophagus, and the liquid remains in the lower esophagus. Occasionally, and particularly in some patients, larger quantities of liquid, sometimes containing food, are refluxed and reach the upper esophagus.

At the upper end of the esophagus is the upper esophageal sphincter (UES). The UES is a circular ring of muscle that is very similar in its actions to the LES. That is, the UES prevents esophageal contents from backing up into the throat. When small amounts of refluxed liquid and/or foods breach (get through) the UES and enter the throat, there may be an acid taste in the mouth. If larger quantities breach the UES, patients may suddenly find their mouths filled with the liquid or food. What's more, frequent or prolonged regurgitation can lead to acid-induced erosions of the teeth.

Nausea

Nausea is uncommon in GERD. In some patients, however, it may be frequent or severe and may result in vomiting. In fact, in patients with unexplained nausea and/or vomiting, GERD is one of the first conditions suspected. It is not clear why some patients with GERD develop mainly heartburn and others develop mainly nausea.

What are the complications of GERD?

Ulcers

The liquid from the stomach that refluxes into the esophagus damages the cells lining the esophagus. The body responds in the way that it usually responds to damage, which is with inflammation (esophagitis). The purpose of inflammation is to neutralize the damaging agent and begin the process of healing. If the damage goes deeply into the esophagus, an ulcer forms. An ulcer is simply a break in the lining of the esophagus that occurs in an area of inflammation. Ulcers and the additional inflammation they provoke may erode into the esophageal blood vessels and give rise to bleeding into the esophagus. Occasionally, the bleeding is severe and may require transfusions of blood and endoscopic (a procedure in which a tube is inserted through the mouth into the esophagus) or surgical treatment.

Strictures

Ulcers of the esophagus heal with the formation of scars (fibrosis). Over time, the scar tissue shrinks and narrows the lumen (inner cavity) of the esophagus. This scarred narrowing is called a stricture. Once the narrowing becomes severe enough (usually when it restricts the esophageal lumen to a diameter of one centimeter), swallowed food may get stuck in the esophagus. This situation may necessitate endoscopic removal of the stuck food. Then, to prevent food from sticking, the narrowing must be stretched (widened). Moreover, to prevent a recurrence of the stricture, the reflux also must be prevented.

Barrett's esophagus

Long-standing and/or severe GERD causes changes in the cells that line the esophagus. These cells then become pre-cancerous, and finally cancerous. This condition is referred to as Barrett's esophagus, which occurs in approximately 10% of patients with GERD. The type of esophageal cancer associated with Barrett's esophagus (adenocarcinoma) is increasing in frequency.

Barrett's esophagus can be recognized visually at the time of an endoscopy and confirmed by microscopic examination of biopsies of the lining cells. Then, patients with Barrett's esophagus may require periodic surveillance endoscopies with biopsies. The purpose of the surveillance is to detect pre-cancerous changes so that cancer-preventing treatment can be started. It is also believed that patients with Barrett's esophagus should receive maximum treatment for GERD to prevent further damage to the esophagus. It is not clear why some patients with GERD develop Barrett's esophagus, but most do not.

Cough and asthma

Many nerves are in the lower esophagus. Some of these nerves are stimulated by the refluxed acid, and this stimulation results in pain (usually heartburn). Other nerves that are stimulated do not produce pain. Instead, they stimulate yet other nerves that provoke coughing. In this way, refluxed liquid can cause coughing without ever reaching the throat! In a similar manner, reflux into the lower esophagus can stimulate esophageal nerves that connect to and can stimulate nerves going to the lungs. These nerves to the lungs then can cause the smaller breathing tubes to narrow, resulting in an attack of asthma.

So, GERD is a common cause of unexplained coughing. Although GERD also may be a cause of asthma, it is more likely that it precipitates asthmatic attacks in patients who already have asthma. Although chronic cough and asthma are common ailments, it is not clear just how often they are aggravated or caused by GERD.

Inflammation of the throat and larynx

If refluxed liquid gets past the upper esophageal sphincter, it can enter the throat (pharynx) and even the voice box (larynx). The resulting inflammation can lead to a sore throat and hoarseness. As with coughing and asthma, it is not clear just how commonly GERD is responsible for otherwise unexplained inflammation of the throat and larynx.

Inflammation and infection of the lungs

Refluxed liquid that passes the larynx can enter the lungs. The reflux of liquid into the lungs (called aspiration) often results in coughing and choking. Aspiration, however, can also occur without producing these symptoms. With or without these symptoms, aspiration may lead to infection of the lungs and result in pneumonia. This type of pneumonia is a serious problem requiring immediate treatment. When aspiration is unaccompanied by symptoms, it can result in a slow, progressive scarring (fibrosis) of the lungs that can be seen on chest x-rays. Aspiration is more likely to occur at night because that is when the processes (mechanisms) that protect against reflux are not active and the coughing reflex that protects the lungs also is not active.

Fluid in the sinuses and middle ears

The throat communicates with the nasal passages. In small children, two patches of lymph tissue, called the adenoids, are located where the upper part of the throat joins the nasal passages. The passages from the sinuses and the tubes from the middle ears (Eustachian tubes) open into the rear of the nasal passages near the adenoids. Refluxed liquid that enters the upper throat can inflame the adenoids and cause them to swell. The swollen adenoids then can block the passages from the sinuses and the Eustachian tubes. When the sinuses and middle ears are closed off from the nasal passages by the swelling of the adenoids, fluid accumulates within them. This accumulation of fluid can lead to discomfort in the sinuses and ears. Since the adenoids are prominent in young children, and not in adults, this fluid accumulation in the sinuses and ears is seen in children and not adults.