Introduction

Reflux disease occurs when stomach contents and digestive juices flow backwards into areas where they should not. This can happen in two main ways: into the oesophagus (the food pipe), or higher up into the throat and voice box. These are known as gastro-oesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR). Although related, they affect different parts of the body, have different symptoms, and may need different treatments.¹ 

Types of reflux disease

• Gastro-oesophageal reflux (GERD): This happens when stomach acid flows back into the oesophagus. GERD is a chronic condition, meaning symptoms last longer and can cause complications if untreated² 
• Laryngopharyngeal reflux (LPR): This is when the stomach’s contents travel higher up, reaching the throat and voice box. Unlike GERD, which is often linked with heartburn, LPR may not always cause burning sensations in the chest, making it trickier to identify³ 

Both conditions are common, and GERD affects men and women equally.¹ 

Symptoms 

Symptoms of GERD may include:

• Heartburn
• Regurgitation (food or liquid coming back up)
• Difficulty swallowing
• Chest pain
• Sour or bitter taste in the mouth
• Unexplained weight loss² 

Symptoms of LPR may include:

• Hoarseness
• Frequent throat clearing
• Chronic cough
• Breathing difficulties
• Postnasal drip
• Difficulty swallowing
• A sensation of a lump in the throat³

 The symptoms of gastroesophageal reflux include:

• Heartburn
• Regurgitation
• Difficulty in swallowing
• Chest pain
• Sour or bitter taste
• Unexplained weight loss

The symptoms of laryngopharyngeal reflux include:

• Hoarseness
• Throat clearing
• Chronic cough
• Breathing difficulty
• Postnasal drip
• Difficulty in swallowing 
• A feeling of a lump in the throat

Causes of GERD

The main cause of GERD is a weak lower oesophageal sphincter (LOS), which normally acts as a barrier between the stomach and oesophagus. Other factors include hiatus hernia, obesity, pregnancy, poor oesophageal movement, reduced saliva, and impaired oesophageal defences.

Risk factors for GERD include:

• Male sex
• White ethnicity
• Older age (over 50)
• Smoking and alcohol use
• Psychosocial stress
• Non-alcoholic fatty liver disease, which has been shown to increase reflux risk¹ 

Diagnosis of GERD

Most cases are diagnosed based on symptoms. Tests are needed when symptoms are unusual or if complications are suspected.

• Proton pump inhibitor (PPI) trial therapy: A common approach is to prescribe PPIs for 8 weeks. If symptoms improve, this supports a diagnosis of GERD. If not, further tests may be needed²
• Ambulatory reflux monitoring: This measures acid reflux in the oesophagus, usually over 24 hours. It helps confirm GERD in people not responding to PPIs²
• Oesophageal manometry: This measures how the oesophagus moves but is mainly done before surgery, not as a first-line test²
• Endoscopy (oesophagogastroduodenoscopy): Recommended in people with symptoms suggesting complications, such as difficulty swallowing, unexplained weight loss, bleeding, or ulcers²
• Imaging studies: X-rays (such as barium swallow) are not usually helpful in diagnosing GERD but may be used to look for hernias or tumours²

Management of GERD

Lifestyle changes: First-line management includes weight loss for people who are overweight, avoiding smoking, alcohol, caffeine, chocolate, and spicy food. Eating smaller meals, avoiding eating close to bedtime, and elevating the head of the bed may help.³

Medication: PPIs are the mainstay of treatment, taken before breakfast. Common examples include omeprazole and lansoprazole. Alternatives include H2 receptor antagonists and prokinetics. PPIs are considered safe in pregnancy.^3,4

Surgery: If medication does not help or complications arise, surgery may be considered. The standard procedure is laparoscopic Nissen fundoplication, which strengthens the LOS. In obese patients, gastric bypass surgery may also improve GERD symptoms.^4,5 Newer, less invasive options include magnetic sphincter augmentation and endoscopic procedures.⁵

Causes of LPR

LPR is mainly due to weakness of the upper oesophageal sphincter. The lining of the voice box is more sensitive than the oesophagus, so even small amounts of acid can cause damage. Changes in the tissues of the throat, such as thickening, swelling, or granulomas (small growths on the vocal cords), are often linked with LPR.^6,7 Problems with oesophageal movement may also contribute.

Diagnosis of LPR

Diagnosis is often based on symptoms and examination of the throat. pH monitoring over 24 hours, using a thin probe placed through the nose, can detect acid reaching the throat. A pH lower than 4 suggests reflux.⁶

Management of LPR

• Lifestyle changes: Similar to GERD, lifestyle measures are important: weight loss, smaller frequent meals, avoiding alcohol, tobacco, caffeine, and carbonated drinks
• Medication: If symptoms persist, PPIs or H2 receptor antagonists may be prescribed. For non-acid reflux, medicines such as alginates or magaldrate can help protect the lining of the throat⁸

Prognosis

Most people with GERD or LPR improve with lifestyle changes and medication. Surgery provides excellent outcomes in selected cases. However, untreated reflux can lead to complications:

• Around 10% of people with GERD may develop Barrett’s oesophagus, a condition that can progress to cancer of the oesophagus⁹
• LPR, if untreated, may cause vocal cord injury and, in rare cases, increase the risk of throat cancer^7,9

Complications

GERD complications:

• Oesophagitis
• Narrowing (strictures)
• Barrett’s oesophagus
• Oesophageal cancer
• Gastrointestinal bleeding
• Dental erosion
• Ulcers
• Sinusitis^2,9

LPR complications:

• Chronic cough
• Laryngitis
• Ulcers in the mouth or throat
• Sinusitis
• Asthma flare-ups
• Idiopathic pulmonary fibrosis (a rare lung condition)^7,8

FAQs

What is the difference between GERD and LPR?

GERD mainly affects the oesophagus and usually causes heartburn and regurgitation. LPR affects the throat and voice box, leading to symptoms such as hoarseness, chronic cough, and a lump-in-throat feeling.

Can reflux disease cause cancer?

In rare cases, long-term untreated GERD can lead to Barrett’s oesophagus, which increases the risk of oesophageal cancer. Untreated LPR may cause damage to the vocal cords and has been linked to a slightly increased risk of throat cancer.

Do I need surgery for reflux disease?

Most people do not need surgery. Lifestyle changes and medicines such as proton pump inhibitors (PPIs) are very effective. Surgery is only considered if symptoms are severe, complications develop, or medication does not work.

Can lifestyle changes really improve reflux symptoms?

Yes. Weight loss, avoiding late-night meals, limiting alcohol, caffeine, and smoking, and sleeping with the head raised can all reduce reflux symptoms significantly.

Is reflux disease the same as indigestion?

Not exactly. Indigestion (or dyspepsia) is a general term for discomfort in the upper stomach. Reflux disease is specifically caused by stomach acid moving into the oesophagus or throat. However, some people experience both at the same time.

Summary

GERD and LPR are related conditions but affect different areas. GERD mainly affects the oesophagus and is often marked by heartburn, while LPR involves the throat and voice box, causing hoarseness, throat clearing, and cough. Both conditions are diagnosed based on symptoms and may require additional tests.

Treatment focuses first on lifestyle changes, then medication such as PPIs, and in severe cases, surgery. Prognosis is generally good if treated early, but complications can develop if reflux is ignored. Recognising the differences between GERD and LPR helps ensure the right management and reduces the risk of long-term damage.