Author: Grant

If you feel burning, tightness or irritation after meals, it’s easy to assume it’s caused by acid. But modern research shows there are actually three different conditions, all of which feel almost identical.

Understanding the difference is the key to choosing the right treatment — and avoiding years of frustration.

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1. “Classic” acid reflux (true GORD)

This is the scenario most people imagine: acid escapes from the stomach and repeatedly irritates the oesophagus.

How to recognise it

• Symptoms correlate strongly with meals
• Lying down can worsen it
• Endoscopy may show oesophagitis
• PH testing shows high acid exposure
• PPIs usually help significantly

This one accounts for less than 30% of people with ongoing heartburn.

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2. Functional heartburn

This describes heartburn-like symptoms where no reflux is actually occurring — acid or otherwise.

How to recognise it

• Symptoms do not consistently match meals
• Normal acid exposure on testing
• Normal oesophageal function
• PPIs don’t help

It’s essentially a misfire of the gut–brain axis, where nerves send pain signals without a physical trigger.

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3. Reflux hypersensitivity

This is the most common — and the most misunderstood — category.

Here, small amounts of normal reflux occur (acidic or non-acidic), but the oesophagus reacts in an exaggerated way.

How to recognise it

• Reflux occurs, but in normal amounts
• Symptoms are out of proportion
• PH testing shows normal acid levels but symptoms correlate with minor events
• PPIs only partially help
• Stress and sleep have a huge effect

You feel every tiny splash, stretch or bubble as if something is wrong — even when it isn’t.

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Why these distinctions matter

Because each condition responds to different treatments:

• True acid reflux: acid-lowering + lifestyle + weight management
• Functional heartburn: gut–brain therapies, mindfulness, TCA/SSRI if needed
• Reflux hypersensitivity: calming the nervous system, regulated eating, gradual exposure to foods, breathing tools, sometimes low-dose neural-modulating medication

This is why many people struggle on PPIs — their symptoms were never caused by acid alone.

Most people use the word reflux to describe any burning or throat irritation after eating. In reality, there are several distinct mechanisms that behave differently and respond differently to treatment. If you’ve been told you have GORD, or if you have throat-heavy symptoms without heartburn, understanding these differences is the first step toward recovery.

Acid reflux
This is the classic form: stomach acid escapes upward when the lower oesophageal sphincter relaxes at the wrong time or pressure builds within the stomach. Acidic content meets a vulnerable lining and causes inflammation. PPIs such as omeprazole reduce acidity, allowing tissue to heal.

Non-acid reflux
Here the material coming up is not acidic because it has been neutralised by food or medication. The problem is not the pH but the movement itself. Non-acid reflux can still trigger symptoms through distension, chemical components of food, or direct contact with the throat. This is why someone can feel burning or tightness even on high-dose PPIs.

Hypersensitive oesophagus
Once inflamed, the oesophagus becomes more reactive. The lining and the nerves beneath it start to fire symptoms from minor stimuli: warm liquids, modest volumes of food, even air movement. In hypersensitivity, the amount of reflux may be small but the perception strong.

Hypertensive upper oesophageal sphincter (UOS)
Some patients develop a tight, overactive upper sphincter. It can be a protective response to previous irritation. It generates throat pressure, difficulty swallowing certain textures and the sense of a lump. This is reversible as inflammation and nerve sensitivity calm.

Strictures
Chronic inflammation can lead to narrowing. Dilation is effective, though it can trigger a temporary flare because the lining is briefly irritated. This does not mean you are back to square one. It is part of the repair cycle.

The encouraging part is that all of this is reversible. With low-irritation habits, measured eating strategies and careful food selection, the oesophagus gradually desensitises and the sphincters return to more normal function. Most people eating a cautious diet can move toward normal eating within several months.