GERD symptoms and causes: heartburn, regurgitation and the less obvious signs

Reflux shows up in two ways. The classic symptoms, heartburn and regurgitation, are easy to recognise. Other symptoms affect the throat, voice, sleep or teeth and are easy to miss. This page covers both, and explains what causes reflux in the first place.

The classic symptoms

Heartburn

Heartburn is the hallmark symptom. Despite its name, it has nothing to do with the heart. It is a burning feeling that starts behind the breastbone or in the upper stomach and can rise towards the throat. It typically comes on after eating, especially after large, fatty or spicy meals, and is often worse when you lie down or bend over, because gravity no longer helps keep acid in the stomach. Many people find it most troublesome in the evening and at night.

Regurgitation

Regurgitation is the effortless return of stomach contents, acidic fluid and sometimes food, into the throat or mouth. Unlike vomiting there is no retching; it simply rises up. The taste is usually sour or bitter. At night it can wake you with a burning or choking feeling.

Heartburn and regurgitation are the two most reliable signs of GERD. When they are the main symptoms and there are no warning signs, doctors can usually diagnose GERD from your description and start treatment without tests.

Chest pain

Reflux is one of the most common non-heart causes of chest pain. It tends to sit behind the breastbone, is often linked to meals or posture, and may ease with antacids. But reflux pain and heart pain can feel very similar, and you cannot reliably tell them apart yourself. Doctors always rule out the heart first.

Difficulty swallowing (dysphagia)

Some people feel food sticking in the throat or chest. Long-term acid exposure can inflame the oesophagus (oesophagitis) or, over time, cause scarring and a narrowing called a stricture. New, persistent or worsening difficulty swallowing should always be checked by a doctor promptly, because it can also be a sign of other conditions, including, rarely, cancer.

Less obvious symptoms

Reflux does not always cause heartburn. When stomach contents reach the throat or voice box, symptoms can look unrelated to digestion. This is sometimes called silent reflux or laryngopharyngeal reflux (LPR). These symptoms have many other possible causes, so guidelines advise checking for those as well rather than assuming reflux.

• Chronic cough: a cough lasting eight weeks or more, often worse at night, after meals or when lying down. Reflux is one of the recognised causes of long-term unexplained cough, alongside asthma and post-nasal drip.
• Hoarseness and sore throat: a rough voice, often worst in the morning, a feeling of a lump in the throat (globus), or frequent throat clearing.
• Disrupted sleep: waking with heartburn, coughing, choking or a sour taste. Overnight, you swallow less often, so acid stays in the oesophagus longer. Reflux and obstructive sleep apnoea often occur together; if you snore heavily and have night-time reflux, mention both to your doctor.
• Dental erosion: acid reaching the mouth can wear away enamel, especially on the inner surfaces of the back teeth and the backs of the upper front teeth. Dentists often notice it first. Rinse with water after a reflux episode and wait before brushing.
• Burping, bloating and feeling full quickly: common alongside reflux, though they also have many other causes.
• Worsening asthma: reflux can aggravate asthma in some people.

What causes GERD?

At its core, GERD happens when the body's barrier against reflux does not work well enough. Understanding that barrier explains why the usual treatments work.

The lower oesophageal sphincter

The lower oesophageal sphincter (LOS) is a ring of muscle at the bottom of the oesophagus. It stays closed except when you swallow, burp or vomit. In GERD it may be too weak at rest, or it may relax briefly at the wrong moments. These brief openings, called transient LOS relaxations, are the most common mechanism behind reflux, and they are triggered especially by a full, stretched stomach after a large meal.

Hiatus hernia

A hiatus hernia is when the top of the stomach pushes up through the diaphragm into the chest. The diaphragm normally reinforces the LOS, so when the stomach slides above it, the seal weakens. Small hiatus hernias are very common in older adults and often cause no symptoms, but larger ones make reflux more likely. See hiatus hernia.

Risk factors

• Excess weight, especially around the abdomen: raises the pressure on the stomach. Weight loss is one of the most effective treatments for people who are overweight.
• Pregnancy: hormones relax the LOS and the growing baby presses on the stomach. See reflux in pregnancy.
• Smoking: weakens the LOS and reduces saliva, which normally helps neutralise acid.
• Alcohol: relaxes the LOS and can irritate the oesophagus.
• Some medicines: including anti-inflammatory painkillers (NSAIDs such as ibuprofen and aspirin), calcium channel blockers for blood pressure, nitrates, some antidepressants, and osteoporosis tablets (bisphosphonates). Never stop a prescribed medicine without talking to your doctor. See medicines that can worsen reflux.
• Conditions affecting the oesophagus: such as scleroderma.
• Age: GERD and hiatus hernia become more common as we get older.

Trigger foods and drinks

Many people notice that certain foods make symptoms worse. The most commonly reported are fatty and fried food, chocolate, coffee, alcohol, fizzy drinks, citrus, tomatoes, spicy food, mint and raw onion. Triggers are highly individual, and guidelines recommend avoiding the foods that affect you rather than cutting out a long list. Look up any food in the food trigger checker and find your own patterns with the symptom diary.

When to see a doctor

Many people manage mild, occasional reflux themselves, and that is reasonable. See a doctor (your GP in the UK) or pharmacist if:

• you have heartburn most days for three weeks or more, or over-the-counter remedies are not helping
• symptoms affect your sleep, meals or work
• you need to take reflux medicine regularly to stay comfortable
• symptoms are changing or getting worse despite treatment
• you have any of the warning signs at the top of this page

In the UK, NICE recommends an urgent endoscopy referral for people with difficulty swallowing, and for people aged 55 and over who have weight loss together with upper abdominal pain, reflux or indigestion. Use the doctor check to see whether your symptoms need attention.