Reflux can cause a wide variety of symptoms. Many people can have reflux and no symptoms at all. Often they can occur suddenly but in most are long-standing and slowly progressive. Some people will have symptoms confined to the stomach and oesophagus (Intestinal symptoms), some the throat (LPR) and some the airways and lungs (Respiratory). Some will have just one symptom, for instance heartburn or a cough and others a multitude of different problems. The important questions are always could my symptoms be caused by reflux and is there another potentially serious or treatable cause?
Heartburn is a pain in the chest behind the breast bone. Some people describe a sharp pain or a tightening sensation or alternatively burning. This is often worse at night, after eating or bending over and the discomfort can move up to the throat or neck. It is often helped by anti-acid medications.
Regurgitation is usually caused by a weak lower oesophageal sphincter. It is a sensation of acid or other stomach contents coming up into behind the breast bone into the throat or mouth. It can be associated with a sour or bitter taste. Frequently precipitated by eating and bending over, regurgitation is often worse at night can wake people from their sleep in a panic with a “feeling of dread” and food in their mouths.
This is a term used by doctors and not by patients. It is describes a variety of symptoms including heartburn, upper abdominal discomfort, burping, nausea and fullness after eating. Dyspepsia has many causes and is not specific to reflux.
Reflux is the most common cause of “non-cardiac chest pain”. It can be severe and even mimic a heart attack. It may be associated with eating or wake people from their sleep. It can be related with oesophageal spasm but a cardiac cause must be ruled out before reflux recorded as the cause.
Otherwise known as dysphagia this can be a symptom associated with reflux. Acid reflux can cause inflammation in the oesophagus (oesophagitis), is associated with motility problems in the oesophageal muscle or cause scarring and narrowing. However, there are other serious causes of dysphagia including cancer and therefore new dysphagia should always be assessed by a doctor.
Reflux is associated with burping for several reasons. It can be caused by a weak lower oesophageal sphincter and often occurs after eating as the pressure differential between the stomach and the oesophagus changes. However, in patients with SIBO and gas production belching can cause reflux symptoms and in those with slow gastric emptying belching will cause reflux symptoms for the same reasons. Occasionally patients learn sub-consciously to help their reflux symptoms with “supra-gastric belching”, when gas is belched from the oesophagus rather than the stomach.
Occasionally patients’ reflux symptoms will be sufficiently severe that they can lose weight, primarily because they tend to avoid eating but occasionally because of associated depression. Weight loss can be secondary to other serious disease and should be investigated by a doctor.
Described as a lump in the throat or neck and sometimes associated with a sensation of “sticking” in the throat on swallowing. In the past this was sometimes thought to be caused by “hysteria” but we now know that it is associated with LPR and sometimes dysfunction of the cricophayngeus muscle (upper oesophageal sphincter).
Some patients ascribe discomfort in their ears to reflux. It's certainly true that there is evidence that reflux can cause these symptoms but in clinical practice it can be very hard to obtain proof from tests.
While not caused by reflux, bloating can be associated with reflux symptoms especially when belching is involved. Patients describe “gassiness”, abdominal discomfort usually after eating and in some cases bloating can become severe enough that it produces a perceptible swelling of the abdomen. There can be associated upper abdominal pain or discomfort.
Otherwise called “dysphonia”, LPR can cause voice weakness, huskiness and for singers subtle difficulties in reaching certain notes.
Patients with LPR often describe a persistent feeling of mucous in their throat and the associated need to clear it. Very often their partners notice it more than patients themselves and it can be an extremely irritating symptom. Throat clearing can be worsened by eating or when lying down at night but often there is no identifiable precipitant.
The sensation of excessive mucus accumulating in the back of the nose dripping down the back of the throat. Often caused by primary sinus problems, persistent chemical irritation of the throat by reflux will cause identical symptoms.
Reflux is one of the most common causes of a persistent cough. Usually non-productive or seasonal, patients often find that it is worse after eating or when lying down. Sometimes anti-acid medications can help. However, it’s a common mistake to think that a failure to respond to PPIs is diagnostic that reflux is NOT responsible as it's thought that it is often caused by relatively non-acidic reflux and there may also be reflex pathways mediated by the nervous system.
Asthma is known to be more common in patients with proven reflux. However, some patients without asthma describe a feeling of shortness of breath especially on exertion or discomfort behind the breast bone with breathing. A rare cause can be a large hiatus hernia when the stomach moves into the chest and compresses the lungs. Very occasionally reflux can cause anaemia and shortness of breath either because of inflammation in the oesophagus (oesophagitis) or in large hiatus hernias because of repeated trauma to the stomach lining causing “Cameron’s erosions”.
Persistent aspiration of acid and other stomach contents into the lungs can cause infections. Sometimes patients known to have reflux will be prescribed repeated courses of anti-biotics. “Bronchiectasis”, a specific chronic lung infection is also associated with reflux.
Page reviewed by: Mr Nicholas Boyle BM MS FRCS 01/11/22