List of symptoms
- Heartburn is the most common symptom. It is a burning sensation in the chest and/or throat. Some people may also experience a sour or acidic taste in their mouth (waterbrash)
- Difficulty swallowing (dysphagia). This is often caused by what is known as esophageal stricture, which is the narrowing of the esophagus. Acid exposure causes damage to the lining of the esophagus, and as this damage heals it forms scar tissue that causes the esophagus to tighten or narrow, which can result in difficulty swallowing. The symptom of difficulty swallowing (dysphagia) always needs investigation to rule out serious causes such as oesophageal cancer. Make an urgent appointment with your doctor if you have dysphagia.
- Dry cough. Some acid reflux sufferers do not have heartburn, but rather experience a dry cough and asthma-like symptoms. This may be mistaken for allergic conditions and the diagnosis of GERD may be missed. If you have a persistent dry cough, then you should consult your doctor.
- Hoarseness and sore throat. Reflux of acid can affect the throat and larynx and may lead to irritation or inflammation that results in a sore throat and/or hoarse voice.
- Acid reflux. Many people can actually feel the experience of regurgitation of food and liquid, often accompanied by a burning sensation in the throat and a sour taste in the mouth.
- Lump in the throat. Some acid reflux sufferers may describe the symptom of a lump in their throat. It is sometimes described as feeling as if food was not swallowed properly and is still sitting in the throat. In some this may result in symptoms of anxiety or occasionally panic or even the sensation of choking.
- Bleeding. Stomach acid can erode the sensitive lining of the lower oesophagus, sometimes causing an oesophageal ulcer (open sore) This lesion can cause pain on swallowing and the ulcer may bleed. This may result in the symptom of vomiting up blood. The bleeding may go unnoticed and if it occurs daily for some time (weeks or months) may result in anaemia.
- Chest pain. The heartburn often associated with GERD can sometimes cause chest pain and may even mimic the symptoms of a heart attack. Studies have found that chest pain caused by acid reflux disease can be ‘squeezing’ in nature and can radiate to the the neck, up into the jaw, and down the arms. If you experience any of these symptoms, it is vital that you seek medical attention immediately to rule out the possibility of a heart attack.
- Erosion of teeth. Since stomach acid may even reflux up into the mouth, it can cause damage to teeth enamel. It is advisable to rinse your mouth with water regularly and brush with a toothpaste that protects tooth enamel.
- Difficulty breathing. This is rare symptom, but some people can even experience the symptom of difficulty in breathing or an inability to take a deep breath. This is because, rarely, the acid irritates the trachea (windpipe) badly enough to affect breathing.
- Barrett’s oesophagus. This is a complication rather than a symptom since it is not something that you will feel or notice. In Barrett’s esophagus, the colour and composition of the esophagus lining will change, when examined via an endoscope. Barret's oesophagus leads to an increased risk of oesophageal cancer. As an acid reflux disease patient, your doctor will monitor this by advising an endoscopy that will help to identify early warning signs.
In more detail
Heartburn is the classical symptom of acid reflux disease, with patients generally reporting a burning feeling, rising from the stomach or lower chest and radiating toward the neck, throat, and occasionally the back. Usually, it occurs after a meal, especially after large meals or the consumption of fatty food, spicy foods, citrus products, chocolate, or alcohol. Lying flat and bending over may worsen heartburn. Acid reflux at night time interferes with restful sleep and may affect work performance on the following day. When heartburn dominates the patient’s complaints, the specificity for GERD is high (89%), but the sensitivity is low (38%). This is when the diagnosis of acid reflux disease is made by an abnormal 24 hour esophageal pH testing. Heartburn symptoms are eased by following an acid reflux diet and medication.
The diagnosis of acid reflux disease is usually based on the occurrence of heartburn on two or more days a week, although less frequent symptoms do not mean that the disease is not present. Although the symptom of heartburn is an aid to diagnosis, the severity and frequency of heartburn do not accurately predict the amount of damage to the esophagus.
Heartburn is caused by the acid stimulation of sensory nerve endings in the deeper layers of the epithelium of the esophagus. These nerve endings are normally protected by an epithelium that is relatively impermeable. But with epithelial changes caused by reflux, they may be stimulated by acid or spicy foods.
Other common symptoms of GERD are acid regurgitation and dysphagia (the symptom of food getting stuck as it passes down the gullet). The effortless regurgitation of acidic fluid, especially after meals and exacerbated by lying down or bending over, is highly suggestive of GERD. Among those people who have regurgitation every day, the pressure of the lower esophageal sphincter (LES) is usually low; many these sufferers have associated slow stomach emptying (gastro-paresis).
Inflammation of the esophagus (esophagitis) is common in this group of patients. For these reasons, the symptom of acid regurgitation may be more difficult to control with medication then the classical symptom of heartburn. More than a 30% of patients with GERD have the symptom of dysphagia. It usually occurs in after a long history of heartburn, with slowly progressive dysphagia primarily for solids.
Dysphagia is a symptom that always needs investigation because it may indicate esophageal cancer. If you have dysphagia see your doctor.
Weight loss is not common in GERD because patients have good appetites.
The most common causes of weight loss are a peptic stricture (narrowing) or Schatzki ring (a narrowing caused by a ring of mucosal tissue or muscular tissue). Patients with Schatzki rings can develop intermittent dysphagia (difficulty swallowing), or, more seriously, a completely blocked esophagus. But other causes of weight loss include severe esophageal inflammation alone, peristaltic dysfunction, and esophageal cancer arising from Barrett esophagus.
Other symptoms of GERD that are less common include burping, belching, water brash, odynophagia, hiccups, nausea, and vomiting.
Water Brash is the sudden appearance in the mouth of a slightly sour or salty fluid. It is known to be secretions from the salivary glands in response to acid reflux rather than regurgitated acid.
Odynophagia is pain on swallowing. It can occasionally be seen with severe ulcerative esophagitis. However, it is symptom that needs investigation because it can be a symptom of other causes of esophagitis, such as infections with candida or herpes. It can also be due to medications such as tetracycline, potassium chloride, quinine, vitamin C, or alendronic acid.
However some patients with GERD may have no symptoms.
This happens especially in the the elderly.This is because of decreased acidity of the refluxed stomach contents or decreased perception of pain. Many elderly patients first go to their doctor because they have symptoms from the complications of GERD. They will have often had long-standing disease with few it has been found that up to a third of patients with Barrett esophagus are insensitive to acid when they see their physician and have tests.
Symptoms caused by GERD which affect other parts of the body.
Doctors are now aware that GERD can also cause a wide range of other symptoms and problems.
- chest pain,
- chronic cough,
- posterior laryngitis,
- recurrent pneumonitis, and
- dental erosion.
Some of these patients have classical reflux symptoms, but many have asymptomatic reflux and are “silent refluxers.” This can make the diagnosis difficult.
In addition it can be difficult to establish a direct causal and effect relationship even if the diagnosis of GERD can be confirmed by tests (e.g. pH studies), because some people may have two common diseases without there being a direct causal relationship.
Acid reflux may cause chest pain which can may mimic angina pectoris. The chest pain of acid reflux is usually described as burning or, less often, squeezing. It is present in the central chest and may radiate to the back, neck, jaw, or arm. It often is worse after meals, and can awaken sufferers from sleep. The pain of heartburn may worsen during periods of emotional stress. It has been found that heavy exercise and even treadmill testing may provoke acid reflux. Reflux-related chest pain may last form a minute to many hours, often resolves spontaneously, and is usually eased with antacids. Most patients with reflux induced chest pain have symptoms of heartburn. Early research suggested that spasm of the muscles of the esophagus were the most common esophageal cause of chest pain. But more recent detailed studies using ambulatory esophageal pH and pressure monitoring suggest that about a quarter to a half of patients with non-cardiac chest pain have a diagnosis of GERD.
Patients with coronary artery disease commonly have both esophageal disease and heart disease, but the evidence that acid reflux causes ischemic angina pain is controversial. The mechanism for reflux-related chest pain is not clearly understood and probably has many causes. It is probably related to the concentration of the acid, the volume and duration of acid reflux, and secondary esophageal muscular spasm.
Asthma and other Respiratory Diseases
The association of acid reflux disease and pulmonary (lung) diseases was recognized as long ago as the late nineteenth century by Sir William Osler, who recommended that asthmatic patients should “learn to take their large daily meal at noon to avoid night-time asthma which occurred if they ate a full supper.” More recent studies suggest that the two diseases co-exist in up to 80% of asthmatic patients, regardless of the use of bronchodilators. The possibility of acid reflux disease should be considered in asthmatic patients who present in adulthood, those who do not have an intrinsic component, and those who do not respond to bronchodilators or steroids. Up to 30% of patients with reflux related asthma have no other esophageal symptoms.
Other lung diseases that are associated with GERD include
- aspiration pneumonia,
- interstitial pulmonary fibrosis,
- chronic bronchitis,
Other possible associations with acid reflux disease are neonatal broncho-pulmonary dysplasia, and sudden infant death syndrome.
Doctors have proposed that the mechanism of reflux-induced asthma is either aspiration of gastric contents into the lungs with secondary bronchospasm or activation of a vagal nerve reflex from the esophagus to the lungs causing bronchoconstriction. Research has found that bronchoconstriction occurs after esophageal acidification, but the response tends to be mild and variable. In contrast, infusion of even tiny amounts of acid into the trachea results in severe and readily reproducible bronchospasm in animals.
The reflux of acid into the trachea as compared with the oesophagus on its own has been shown to cause significant changes in peak expiratory flow rates in sufferers from asthma. Although either mechanism may be the cause of acid reflux induced asthma, most patients probably suffer from intermittent aspiration of small amounts of acid.
Ear, nose, and throat diseases
Acid reflux disease may be associated with a many laryngeal problems and symptoms. Reflux laryngitis is probably the most common. Patients with reflux laryngitis have symptoms of hoarseness, globus sensation (lump in throat), frequent throat clearing, recurrent sore throat, and prolonged voice warm-up.
Ear, nose, and throat physical signs which are attributed to GERD include posterior laryngitis with edema (fluid swelling) and redness. Plus vocal cord ulcers and granulomas, leukoplakia, and even carcinoma. These changes are usually restricted to the posterior third of the vocal cords and inter-arytenoid regions. Both of which are in close proximity to the upper esophageal sphincter.
Acid reflux disease is the third most common cause of chronic cough (after sinus problems and asthma) and probably accounts for about 20% of cases of chronic cough.
Dental erosion, which is defined as the loss of tooth structure by chemical processes which do not involving bacteria, can be caused by acid reflux in healthy people and in patients who have bulimia. Despite the association between ear, nose, and throat diseases and acid reflux disease, overt esophagitis is usually not present. Most patients have only mild reflux symptoms or have no symptoms. The aspiration of small amounts of stomach acid thought to be the most likely cause of these ear nose and throat problems.
Research has shown that the combination of acid and pepsin is damaging to the larynx. Studies also show that lower esophageal acid exposure, particularly at night during sleep, is significantly more common in people who have laryngeal symptoms and signs.