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Urgent
ESOPHAGEAL HYPERSENSITIVITY: THE HIDDEN “CULPRIT” BEHIND FAILED REFLUX TREATMENT
Normal endoscopy, so why do I still have a burning sensation?
Master, Doctor Mai Vien Phuong, Head of the Gastrointestinal Endoscopy Unit at American International Hospital (AIH), shares:
In clinical practice, doctors often encounter patients who wonder:
“I’ve had two endoscopies, and the doctors said there is no longer any inflammation in my esophagus.”
“I’ve also been taking acid-suppressing medication for almost a year.”
“So why do I still have a burning sensation behind my breastbone every day?”
This is not an uncommon situation in clinical practice. Many patients feel confused when endoscopy results are almost normal and tests show no obvious abnormalities, yet the burning sensation, retrosternal pain or discomfort, or chest discomfort persists.
Some patients begin to question the accuracy of their endoscopy results. Others worry that they may have a serious underlying condition that has not yet been detected. Some continue to purchase medications on their own or prolong their use of acid-suppressing drugs in the hope that their symptoms will eventually disappear.
According to Master, Doctor Mai Vien Phuong, in many cases, the problem is not caused by excessive gastric acid secretion or persistent inflammation of the esophagus. Instead, it may be related to esophageal hypersensitivity, a condition in which the esophagus becomes overly sensitive to stimuli that would normally be considered harmless.
This is a functional disorder that is receiving increasing attention from gastroenterologists, but remains relatively unfamiliar to many patients.
Therefore, some patients may continue to experience persistent symptoms even after receiving appropriate treatment for reflux and after the esophageal mucosa has healed.
What Is Esophageal Hypersensitivity?
To understand this condition, we first need to understand how the esophagus normally functions.
Every day, even in healthy individuals, a small amount of gastric contents naturally refluxes into the esophagus. This is a normal physiological phenomenon and typically does not cause any discomfort.
In addition to acid, the esophagus is also exposed to various other stimuli, such as:
Hot or cold food and beverages.
Contractions during swallowing.
Air passing through during belching.
Small amounts of digestive fluid.
In healthy individuals, these stimuli are generally not perceived.
However, in people with esophageal hypersensitivity, the pain perception threshold is lowered. Even a very mild stimulus can produce a sensation of burning or pain.
Simply put, the problem is not that the stimulus is too strong, but that the esophagus responds too strongly to a normal stimulus.
A Simple Example
Imagine that you have just gotten sunburned.
When your skin is healthy, a light touch causes little to no sensation.
But after getting sunburned, even the slightest friction from clothing against your skin can cause a burning sensation.
This does not mean that the clothing is exerting more force than before.
Rather, your skin has become more sensitive.
The same principle applies to the esophagus.
After months or years of repeated exposure to acid, the nerve endings in the esophageal wall may become “hypersensitive.” As a result, even after acid exposure has been significantly reduced with treatment, patients may continue to experience a burning sensation.
Why Does the Esophagus Become Hypersensitive?
This is a question that has been extensively studied in recent years.
Currently, scientists believe that there is no single cause. Instead, multiple factors may work together.
1. Prolonged Exposure to Acid
Acid là tác nhân đầu tiên.
If acid repeatedly refluxes into the esophagus over a period of months or years, the esophageal lining is repeatedly irritated.
Initially, this may cause only mild inflammation.
Over time, however, the nerve endings can become more sensitive.
Even after the inflammation has healed, the nervous system may continue to respond excessively.
2. Overactive Nerves
The esophageal wall contains numerous nerve endings that detect::
Temperature.
Pressure.
Acid.
Distension.
In healthy individuals, these nerves send signals only when the stimulus is sufficiently strong.
In people with esophageal hypersensitivity, even a very small stimulus can be enough to send a signal to the brain.
It is like a microphone with its volume turned up too high.
Even a whisper can produce a very loud sound.
3. The Brain Also Contributes to the Symptoms
The Brain Also Contributes to the Symptoms
The brain also plays a role in the perception of pain.
Normally, the brain is able to “filter out” minor signals so that we do not consciously perceive every stimulus occurring in the body.
In some people, this mechanism does not work as effectively.
As a result, with the same amount of acid exposure, one person may experience little to no sensation, while another may experience a pronounced burning sensation.
This is why two people with very similar test results can experience completely different levels of discomfort.
4. Prolonged Stress
Stress does not directly cause esophageal hypersensitivity, but it can make the condition worse.
During prolonged periods of stress:
The brain becomes more sensitive to pain.
Patients become more focused on their symptoms.
Sleep quality worsens.
Quality of life declines.
Many people notice that their symptoms become worse during periods of work-related stress or sleep deprivation.
What Signs Suggest Esophageal Hypersensitivity?
Patients commonly experience symptoms such as:
Persistent retrosternal burning.
Non-cardiac chest pain.
A burning sensation after eating.
Symptoms that persist despite appropriate medication use.
Normal endoscopy findings or only mild inflammation.
Little improvement despite taking additional acid-suppressing medication.
These symptoms can easily be mistaken for those of typical gastroesophageal reflux disease.
How Is Esophageal Hypersensitivity Different from Reflux Disease?
This is an important distinction.
In reflux disease, the primary cause is an excessive amount of gastric fluid refluxing back into the esophagus.
In contrast, with esophageal hypersensitivity, the amount of reflux may be completely normal.
The difference lies in how the esophagus perceives stimuli.
It can be compared to two people entering the same room at a temperature of 25°C.
One person feels perfectly comfortable.
The other feels that it is too cold.
The temperature has not changed.
What has changed is the body’s sensitivity to the stimulus.
Does a Normal Endoscopy Rule Out the Condition?
The answer is no.
Endoscopy allows doctors to examine the surface of the esophageal mucosa.
However, endoscopy cannot assess:
The sensitivity of the esophagus.
Nerve activity.
The relationship between symptoms and episodes of reflux.
This is why many people may have completely normal endoscopic findings but still experience symptoms.
How Is It Diagnosed?
There is no single test that can definitively diagnose esophageal hypersensitivity.
Doctors will consider a combination of:
Clinical symptoms.
Endoscopy findings.
Response to treatment.
24-hour esophageal pH-impedance monitoring when necessary.
Esophageal manometry in certain cases.
The most important consideration is determining whether the patient’s symptoms are associated with episodes of reflux.
Is Treatment Difficult?
The good news is that this condition can be effectively managed when it is correctly diagnosed.
Treatment does not focus solely on acid.
Depending on the individual patient, the doctor may:
Adjust medications used to treat reflux.
Reduce esophageal sensitivity with appropriate medications when indicated.
Recommend lifestyle modifications.
Manage stress and improve sleep.
Treat any underlying or coexisting conditions, if present.
Most importantly, patients should not continue to increase the dose of acid-suppressing medication over the long term when acid is no longer the underlying cause of their symptoms.
Don’t Try to Live with the Symptoms for Years
Many people accept living with a burning sensation because they believe that the condition is not dangerous.
However, persistent symptoms can significantly affect:
Sleep.
Work performance.
Mood.
Quality of life.
An accurate evaluation of the underlying cause can help patients choose the appropriate treatment approach and avoid unnecessary long-term medication use.
Treating Esophageal Conditions Requires Collaboration Between Patients and Doctors
Treatment Is More Than Prescribing Medication
At the Department of Gastroenterology – American International Hospital, we believe that successful treatment depends on more than medication or test results. Every patient is unique, with their own circumstances, work, lifestyle habits, and sources of stress.
During each consultation, we do more than simply review endoscopy results or previous prescriptions. We take the time to listen to each patient’s story, understand what is causing them concern, and learn about the challenges they face in their daily lives. Based on this understanding, the doctor works together with the patient to develop a treatment plan tailored to the underlying cause of the condition, their lifestyle, and their individual treatment goals.
If you have been receiving treatment for reflux for a long time but continue to experience burning behind the breastbone or unexplained chest pain, please visit the Department of Gastroenterology – American International Hospital for a comprehensive evaluation by a specialist. Sometimes, only by identifying the underlying cause can treatment truly become effective and help you regain your quality of life.
Key Takeaways
Esophageal hypersensitivity is a common cause of persistent symptoms in people who have been treated for reflux without improvement.
A normal endoscopy does not necessarily mean that there is no underlying condition.
The issue may lie in changes in how the esophagus perceives stimuli, rather than excessive acid production.
Effective treatment requires identifying the correct underlying cause, rather than simply increasing medication.
Individualized treatment and collaboration between doctors and patients are important for long-term symptom control.
Reference list
Sawada A, Sifrim D, Fujiwara Y. Esophageal Reflux Hypersensitivity: A Comprehensive Review. Gut and Liver. 2023;17(6):831–842.
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