Sam Cansfield was sat at her desk sipping coffee when she suddenly felt a crushing pressure build in her chest.
The sensation caught fit and healthy Sam, 54, by surprise, but as the effect ‘was fairly brief’, she thought no more of it.
But mysteriously over the next two weeks it happened again and again – and Sam developed a tingling sensation in her throat and a runny nose, too, though she didn’t have a cold.
‘It was just such an odd feeling and I didn’t know what was causing it,’ recalls Sam.
She also occasionally felt like she had a lump in her throat and on occasion even felt as if she was choking.
After three weeks, Sam, who works in property and lives near Hertford, saw her GP, who sent her for an electrocardiogram, suspecting it was a problem with her heart rhythm.
Sam Cansfield, a fit and healthy 54-year-old, developed a tingling sensation in her throat and a runny nose, too, though she didn’t have a cold
When that came back clear, the GP offered no more tests.
‘I was really worried at this point, as no one seemed to know what the problem was,’ says Sam.
‘But all the time, the chest pressure, the running nose and the strange creeping feeling in my throat kept getting worse.
‘The symptoms were worse after I ate anything, every time I drank coffee. But it was there in some form all the time.’
Concerned there was something seriously wrong, in November 2020, Sam made an appointment with a private GP online who identified the problem as a form of reflux, which surprised Sam, ‘as I didn’t have typical reflux symptoms’, she says.
There was a reason for that – she didn’t have typical reflux.
Reflux normally occurs when the acidic stomach contents leak up into the food pipe, typically causing heartburn (a burning sensation in the chest) and nausea – but Sam had what is known as silent reflux.
Also called laryngopharyngeal reflux (LPR), it causes symptoms focused on the throat, nose and chest, such as a cough, sore throat, the need to constantly clear the throat or a feeling of having a lump in the throat.
Silent reflux – like all reflux – begins when the valve between the stomach and the bottom of the oesophagus (the food pipe), becomes weaker, allowing powerful acid and other stomach contents to escape.
Risk factors include being overweight, as this can put pressure on the stomach valve, or smoking, a hernia (where part of the stomach pushes up into the chest) and suffering from stress and anxiety.
Diet can also contribute to reflux as certain food and drink, such as coffee, tomatoes, alcohol, chocolate and fatty or spicy foods, can prompt the production of excess stomach acid and make the valve relax.
But there may be no obvious reason why it develops, according to the NHS.
It is not fully understood why some patients experience silent symptoms while others have a more classic heartburn sensation.
One theory is that irritating substances escape from the stomach suspended in a spray, rather than the rush of liquid acid which is usually behind heartburn, says Nick Boyle, a consultant upper gastrointestinal surgeon and medical director of the Reflux UK, a specialist private clinic with centres across the UK.
This spray can travel up the oesophagus and reach the throat, voice box, the back of the mouth – and even up to the sinuses behind the nose to create the wide range of symptoms, says Mr Boyle.
Some patients develop a husky or weak voice as the acid irritates their voice box, or some suffer sinus problems, a streaming nose and a nasty taste in their mouth.
As the stomach spray can be inhaled into the lungs, in some cases the condition can lead to persistent chest infections.
‘It is called silent reflux as it doesn’t come with heartburn, but I have always thought it is not a good name,’ says Mr Boyle.
‘A lot of people have these symptoms and it is not silent – it troubles them a lot.’
While one in four people in the UK has some form of reflux, according to the charity Gut UK, silent reflux is not recorded separately from other types.
However a UK study of almost 380 randomly selected people, published in the European Archives of Oto-Rhino-Laryngology in 2012, found one in three had symptoms of silent reflux.
The problem is that, in the absence of heartburn, many people with silent reflux struggle for years without a diagnosis, says Mr Boyle.
Dr Rehan Haidry, a consultant gastroenterologist at the private Cleveland Clinic in London, says that about 10 per cent of his reflux patients have the silent form and some of those will have been told wrongly that they had asthma.
But a prompt diagnosis is important as any form of reflux raises the risk of Barrett’s oesophagus, where the cells in the lining of the oesophagus undergo change as a result of the constant exposure to acid.
And up to 13 per cent of those with Barrett’s oesophagus will develop oesophageal cancer, according to Cancer Research UK – which is why people who have it are monitored for signs of cancer.
Reflux is often diagnosed simply by a doctor taking a history of symptoms, but if the diagnosis is in doubt then some may be referred for a gastroscopy, where a small camera is put down the throat to check the oesophagus and stomach.
If silent reflux is suspected, then another test that may be carried out involves a small capsule being inserted into the oesophagus (via a tiny tube, called a catheter), which remain in place for 24 hours to measure pH levels, which it monitors wirelessly. Low pH could be a sign of acid.
After surgery, Sam can eat anything she wants again – and even drink coffee, which once exacerbated her symptoms
Whatever the form of reflux, treatment is the same.
It starts with lifestyle changes, such as losing weight if appropriate and taking antacids, which neutralise stomach acid to stop it irritating the oesophagus lining.
Another option is alginates, which come as liquid and tablets and form a protective barrier on top of the contents of the stomach to stop it rising up into the oesophagus.
‘We use Gaviscon Advance liquid a lot, which is an alginate, and find it works well for many patients,’ says Mr Boyle.
Patients may also be prescribed drugs called proton pump inhibitors (PPIs), which help by reducing production of stomach acid.
However, these tend to be less effective for silent reflux as in this case it’s not just the stomach acid that is causing the problem – a number of different substances found in the stomach (including bile and pepsin, a stomach enzyme) – contribute to it.
(These substances are involved in other forms of reflux too, but they seem particularly important in LPR, for reasons not fully understood.)
‘PPIs only work for about 20 per cent of people with silent reflux,’ says Mr Boyle.
‘And there is a misconception among many doctors that if PPIs don’t work then it isn’t reflux.’
If people with silent reflux don’t improve on PPIs after six weeks, then they should be stopped, says Mr Boyle.
He adds that often patients are switched to higher doses, or different PPIs – however, these are unlikely to work and could actually worsen the problem, as the drugs suppress the production of acid which can lead to an overgrowth of bacteria, called small intestinal bacterial overgrowth (SIBO), which can lead to bloating and belching – and even a worsening of the reflux.
Tests showed Sam also had excessive production of stomach acid due to triggers such as coffee.
During surgery, it was also discovered that Sam had a hernia that was weakening the valve at the top of her stomach; her stomach was pushing up into her chest.
After Sam’s diagnosis in November 2020, she tried a PPI and another type of medication which reduces acid production, called a H2-blocker, but neither worked.
She cut out tea, coffee and food high in fat and tried not to eat too close to bedtime and slept sitting up, supported by pillows, to stop the reflux while she slept.
‘My symptoms, including the chest pressure and the runny nose, continued despite everything I tried, and I was living on a diet of antacids, going through bottles and bottles of Gaviscon,’ she says.
‘I was practically drinking it for months, taking it after everything I ate.’
Risk factors include being overweight, as this can put pressure on the stomach valve, or smoking, a hernia (where part of the stomach pushes up into the chest) and suffering from stress and anxiety
As the symptoms persisted, Sam decided she needed a different approach.
‘It was just a horrible experience and I wanted it sorted out properly. So, while it felt like a big step, I decided to go ahead with surgery.’
This is usually reserved for severe cases that don’t respond to other measures.
Typically this takes the form of an operation called a fundoplication, where keyhole surgery is used to wrap the top of the stomach around the bottom of the oesophagus to tighten the valve to stop stomach contents escaping.
Sam had a newer procedure carried out privately by Dr Haidry, called a transoral incisionless fundoplication, which is carried out with instruments and a camera inserted through down the throat, making it less invasive.
The oesophagus is pushed into the top of the stomach which is and stitched into place. Studies show this creates a new stronger valve between the stomach and the gullet, to stop acid flowing back out, although there is a small risk of side effects such as difficulty belching and swallowing and bloating.
Other newer options for surgery include using a small band of magnets around the base of oesophagus just above the stomach to strengthen the valve.
It took Sam a year to fully recover from the operation in the summer of 2021, but the effects have been transformative.
‘I don’t get symptoms any more – I can drink coffee and I can eat anything I want to,’ she says.
‘I don’t worry about going to sleep or being woken by my symptoms, and I can sleep lying down again, instead of propped up on cushions.
‘It has changed my life.’