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    Adult - Presenting symptoms

    Presenting symptoms in adults

     

    Typical and atypical symptoms of reflux

    In order to treat patients appropriately and effectively, it is important to distinguish common symptoms associated with reflux, such as heartburn, from symptoms like indigestion.

    Key symptoms for each are as follows:

    Reflux (including heartburn) Indigestion (Dyspepsia)

    Symptoms are predominantly in the throat and chest, and typically include:(1,2)

    • A burning sensation in the middle of the chest, which can move up towards the throat
    • An unpleasant sour taste in the mouth caused by gastric content regurgitation
    • Water brash (hypersalivation)(3)

    Symptoms are predominantly in the stomach and upper abdomen, including:(1,4)​

    • Feeling full and bloated
    • Pain in the upper abdomen
    • Belching and increased wind

    Look out for the key words above when patients describe their symptoms. This will help you to identify whether the patient is experiencing heartburn or indigestion.

    Atypical symptoms of reflux can also occur with or without the presence of typical symptoms. These include:(3)

    • Epigastric pain or chest pain – which may mimic ischaemic cardiac pain
    • Respiratory symptoms such as coughing, wheezing, chronic rhinosinusitis
    • Ear, nose and throat (ENT) symptoms

     

    Red flag symptoms

    Patients may also describe 'red flag symptoms', which may require further medical advice:(3)

    In the pharmacy setting, any patient describing more than one of these symptoms or who is over the age of 50 with persistent new-onset symptoms, should be referred to their doctor. (5)

     

    Symptoms in pregnancy

    Up to 80% of pregnant women experience reflux symptoms.(6,7) Symptoms such as heartburn, (8) a sour taste in the mouth and regurgitation(8) can occur in any trimester but generally become more frequent and severe as the pregnancy evolves (8,9) and at night-time.(10)

    For more information on how to manage pregnant women experiencing reflux symptoms, visit our case study on Maria's story.

     

    Breakthrough symptoms in GORD patients

    Patients with chronic reflux can be categorised into:(11)

    • Erosive reflux disease (ERD) – patients with visible breaks in the oesophageal mucosa
    • Non-erosive reflux disease (NERD) – troublesome reflux-related symptoms in the absence of visible lesions in the oesophageal mucosa

    Most patients are treated with proton pump inhibitors (PPIs) to manage their symptoms. However, breakthrough symptoms such as heartburn, regurgitation and night-time symptoms can occur.(12)

    PPIs reduce the acidity and size of the acid pocket.(13) However, other factors not maintained by PPIs, can still contribute to symptoms in patients:

    • Persistence of the smaller and weaker acid pocket, which is still able to seep into the oesophagus(13)
    • Presence of other aggressors such as bile and pepsin in the refluxate(14,15)
    • Enhanced susceptibility due to dilated intracellular spaces (DIS) between oesophageal epithelial cells(16)
    • Acid hypersensitivity due to altered mucosal sensory nerve distribution(17)

    For more information on how to manage GORD patients with breakthrough symptoms, visit John on our case study page.

    References

    1. World Gastroenterology Organisation Global Guidelines. Coping with common GI symptoms in the community. 2013. Available: http://www.worldgastroenterology.org/guidelines/global-guidelines/common-gi-symptoms/common-gi-symptoms-english [accessed August 2019]
    2. NHS UK. Heartburn and reflux. 2017. Available: https://www.nhs.uk/conditions/heartburn-and-acid-reflux/ [accessed August 2019]
    3. World Gastroenterology Organisation Global Guidelines. Global Perspective on Gastroesophageal Reflux Disease. 2015. Available: https://www.worldgastroenterology.org/guidelines/global-guidelines/gastroesophageal-reflux-disease/gastroesophageal-reflux-disease-english [accessed August 2019]
    4. NHS UK. Indigestion. 2017. Available: https://www.nhs.uk/conditions/indigestion/ [accessed August 2019]
    5. Basu KK. Concise guide to management of reflux disease in primary care. Prescriber 2012;23(15–16):19–28
    6. Richter JE. Review article: the management of heartburn in pregnancy. Aliment Pharmacol Ther 2005;22(9):749–57
    7. Ramya RS, Jayanthi N, Alexander PC, et al. Gastroesophageal reflux disease in pregnancy: a longitudinal study. Trop Gastroenterol 2014;35(3):168–72
    8. Fill Malfertheiner S, Malfertheiner MV, Kropf S, et al. A prospective longitudinal cohort study: evolution of GERD symptoms during the course of pregnancy. BMC Gastroenterology 2012;12:131
    9. Ramu B, Mohan P, Rajasekaran MS, et al. Prevalence and risk factors for gastroesophageal reflux in pregnancy. Indian J Gastroenterol 2011;30(3):144–47
    10. Strugala V, Bassin J, Swales VS, et al. Assessment of the Safety and Efficacy of a Raft-Forming Alginate Reflux Suppressant (Liquid Gaviscon) for the Treatment of Heartburn during Pregnancy. ISRN Obstet Gynecol 2012;2012:481870
    11. Savarino E, Zentilin P, Savarino V. NERD: an umbrella term including heterogeneous subpopulations. Nat Rev Gastroenterol Hepatol 2013;10(6):371–80
    12. Kahrilas PJ, Jonsson A, Denison H, et al. Regurgitation is less responsive to acid suppression than heartburn in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2012;10(6):612–19
    13. Rohof WO, Bennink RJ, Boeckxstaens GE. Proton pump inhibitors reduce the size and acidity of the acid pocket in the stomach. Clin Gastroenterol Hepatol 2014;12(7):1101–7
    14. Johnston N, Dettmar PW, Bishwokarma B, et al. Activity/stability of human pepsin: implications for reflux attributed laryngeal disease. Laryngoscope 2007;117(6):1036–39
    15. Nehra D, Howell P, Williams CP, et al. Toxic bile acids in gastro-oesophageal reflux disease: influence of gastric acidity. Gut 1999;44(5):598–602
    16. Woodland P, Batista-Lima F, Lee C, et al. Topical protection of human esophageal mucosal integrity. Am J Physiol Gastrointest Liver Physiol 2015;308(12):G975–80
    17. Woodland P, Shen Ooi JL, Grassi F, et al. Superficial Esophageal Mucosal Afferent Nerves May Contribute to Reflux Hypersensitivity in Nonerosive Reflux Disease. Gastroenterology 2017;153(5):1230–39

     

    RB-M-02499
    Date of preparation: June 2020

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