What
is Acid Reflux Complete
Guide on Acid Reflux
Acid
reflux is the most common gastrointestinal disorder; more than half of adults
experience it at least once in their life. According to The American College of
Gastroenterology, over 60 million Americans have acid reflux and heartburn once
a month and 15 million face this daily. If acid reflux occurs more than twice a
week, the condition is referred to as gastroesophageal reflux disease (GERD). While
reflux occurs mostly in people over 40 years of age, it can occur in children
and infants too.
Pathology
When
we swallow food, it passes from the mouth into a tube called the esophagus, and
then travels down to the stomach. At the entrance of the stomach or lower end
of the esophagus, there is a ring of muscles that form a valve called a lower
esophageal sphincter (LES).
In
normal conditions, this sphincter opens when a wave of food comes down the
esophagus and touches it and then closes as soon as food passes through it. In
abnormal conditions, this sphincter either doesn’t close properly or is more open
than normal.
The
esophagus can resist the abrasion by food but cannot withstand acid coming up from
the stomach. Thus, when the acid in the stomach passes the LES into the
esophagus, which is referred to as acid reflux, people will experience pain,
irritation, or a burning sensation in the lining of the esophagus and center of
the chest. This chest discomfort is often called heartburn and, in some cases,
may even resemble the chest pain of a heart attack.
Acid
reflux can also cause a sour taste in the backside of your mouth and can lead
to nausea, hiccups, cough, bad breath, bloating, and feeling of sickness. These
symptoms will be increased if the person has a habit of lying down immediately
after eating food.
Causes
of acid reflux
When
the valve separating the stomach and esophagus, called lower esophageal
sphincter (LES) is weakened or fails to do its job, contents of the stomach
regurgitates into the esophagus. This is known as acid reflux.
The
symptoms of acid reflux mostly occur in periods of transient lower esophageal
sphincter relaxation (TLESRs), which is a period during which stomach vents its
gases. People with this disorder are more likely to experience symptoms during
this period.
Another
cause contributing to the symptoms is the positioning of acid pockets. When
acid pockets are above diaphragm during TLESRs, the more frequent the symptoms
will occur.
One
of the most common causes of acid reflux is hiatal hernia. This is a stomach
abnormality in which the upper part of the stomach and LES herniates into the
lower esophagus. In the case of hiatal hernia, the diaphragm, which normally
keeps the acidic content inside the stomach, is unable to perform this function
and acid moves upward causing symptoms of acid reflux.
Other
various causes of acid reflux are as follows:
- Overweight or obesity
- Consuming large meals
- Lying down immediately after meals
- Eating certain foods; tomato, onion, chocolates, fatty
and spicy foods.
- Drinking beverages which include alcohol, coffee, tea,
and carbonated drinks
- Smoking
- Pregnancy
- The intake of non-steroidal anti-inflammatory drugs
(NSAIDs), aspirin, ibuprofen, muscle relaxants, and hypertension medications
may cause the disease.
Risk
Factors
These
behaviors and conditions increase the risk for the development of acid reflux
Hiatal Hernia:
As explained earlier, hiatal hernia is caused due to displacement of the junction between stomach and esophagus. This is a major risk factor for acid reflux and reflux esophagitis.
Obesity:
Obesity,
especially central adiposity and being overweight, results in an increased risk
of acid reflux. This is because central adiposity increases the gastric
pressure and changes the gradient across LES, which leads to acid reflux.
Obesity also increases the chances of hiatal hernia, which ultimately causes
GERD.
Tobacco
smoking:
There
is an increased risk of developing acid reflux with tobacco smoking. Smoking
causes damage to mucus lining, which causes more release of acid. Smoking also reduces
the tone of LES and reduces the secretion of saliva, which when being produced
in normal amounts, neutralizes the effects of acid. In addition, there is an increased
risk of esophageal cancer with smoking. The duration and the amount of tobacco consumed
greatly alters the risk percentage; the more and longer you smoke the higher
the risk.
Alcohol
Consumption:
Evidence
suggests that mild to moderate alcohol consumption, more than 7 drinks per week,
is linked to an increased risk of acid reflux.
Helicobacter
Pylori infection:
The
link between H. pylori and peptic ulcer disease is well established. However, the
link between H.pylori and acid reflux is not as clear. Some research suggests
that the presence of H. pylori infection actually decreases the risk of GERD. Therefore,
more research is needed on the risk of acid reflux due to H.pylori.
Pregnancy:
Increased
levels of progesterone causes relaxation of LES. This increases the risk of
GERD in pregnant women by 40-85%. Pregnancy not only precipitates the symptoms,
but may also worsen them. Symptoms usually occur at the end of 1st trimester
and continue worsening till the end of gestation, at which point typically
resolve after giving birth. Although symptoms may be severe in pregnancy,
complications are rare to occur.
Genetics:
There
is some evidence of the genetic cause of GERD. For example, a study on twins
showed the risk of acid reflux in identical twins was increased by 435% and in nonidentical
twins by 26%.
Medications:
In
addition to NSAIDs, there are a lot of other medications that can increase the
risk of GERD. These medications include antibiotics, ACE inhibitors, vitamin C,
potassium, quinidine, anticholinergics, corticosteroids (both oral and
inhaled), nitroglycerines, aminophylline, warfarin, statins, and calcium
channel blockers (CCBs).
Scleroderma:
A
connective tissue disorder may increase the risk percentage of reflux disease.
Delayed
gastric emptying
Those
with a slow GI transit time have a higher risk of acid reflux. This is because
the food is staying in the stomach for longer periods of time.
Food
and Beverages
Consuming
excessive amounts of caffeine, sugar, tomato, fatty and spicy foods, citrus
products, and carbonated beverages increase risk.
Symptoms
The
most common signs and symptoms of acid reflux are heartburn, regurgitation,
nausea, and sore throat.
Heartburn:
After
eating, a burning sensation is produced in the throat, chest, or abdomen. This
burning sensation will typically be heightened if you lie down right after
eating or if you consume an especially large, spicy, fatty, or acidic meal.
Heartburn
can sometime be confused with a heart attack, but can be differentiated by
following patterns specific only to heartburn:
- Pain doesn’t radiate to shoulders, neck, or arms
usually.
- Pain always follows some meals that usually trigger
reflux.
- Pain is relieved by antacids.
If your
chest pain does not follow these patterns, is getting worse, or fails to
improve with antacids, or if you are just unsure, call 911.
Regurgitation:
A
sour, bitter, acidic taste that occurs in the back of the throat or in the mouth
called regurgitation. This occurs when acid from the stomach or food from the
stomach goes though the LES and into the esophagus.
Other
less common symptoms
- Non-cardiac chest pain
- Difficulty in swallowing (Dysphagia)
- Painful swallowing (Odynophagia)
- Bloating
- Bloody vomiting
- Bloody, black stools
- Globus sensation including the sensation of fullness and
sensation of a lump in the throat. This is caused by increased tonicity of the
upper esophageal sphincter (UES) due to acid reflux.
- Burping
- Hiccups
- Nausea
- Bronchospasm is triggered which may lead to cough
dyspnea and wheezing, which may worsen asthma
- Laryngitis
- Anemia
- Weight loss for no other obvious reason
Diagnosis
Classic
symptoms of heartburn and regurgitation are enough for a doctor to diagnose
acid reflux. If lifestyle changes and medications don’t relieve the symptoms,
or if symptoms get more severe with time, your doctor may order the following
tests:
Endoscopy:
A
sedative is given to the patient and a tube with a camera is inserted through
the mouth, into the esophagus, to see the lining of the esophagus and stomach.
This procedure takes about 20 mins and should be relatively painless.
Barium
Swallow Radiograph (Esophagram):
This
is a special X-ray procedure in which you are asked to swallow barium. The
barium will coat the lining of your esophagus and stomach and will light up as
white on the x-ray. This will allow your provider to detect if you have any
structural or lining problems in your stomach or esophagus.
Biopsy:
A
small surgical instrument is inserted in the esophagus and a small piece of the
lining in the esophagus is removed to rule out esophageal cancer.
Esophageal
Manometry:
A
tube is inserted through the nose into the stomach and you are asked to lay
down on your left side. The functions of esophagus and LES are assessed through
muscle contractions detected by sensors.
pH
monitoring:
A pH
monitor is inserted into the esophagus through your nose and the acidity is
monitored over 24 hours. A new wireless version of this test is being used
now.
Treatments
Diet
Changes:
- Eat smaller, but frequent meals
- Don’t lie down 1-2 hours after eating
- Raise one side of your bed at least 4-6 inches
- Avoid tight clothes
- Try to lose weight if you are obese
- Stop smoking
- Avoid alcohol
- Avoid fatty or spicy foods, citrus foods, chocolate, carbonated
beverages, alcoholic beverages, caffeine, tomatoes, onions, garlic, or other
trigger foods
Medications:
- OTC antacids can neutralize the acid from your stomach,
but their overuse can cause diarrhea or constipation. Use antacids with
aluminum hydroxide and magnesium hydroxide such as TUMS.
- Foaming agents or alginate drugs (Gaviscon)
- H2 Blockers: cimetidine, famotidine
- Proton pump inhibitors (PPI): omeprazole, rabeprazole
- Prokinetics
Surgery:
LINX
device to help to avoid acid reflux by preventing stomach contents into the
esophagus.
Fundoplication
is applied to artificially induce valves on top of your stomach and strengthens
the LES.
Complications/Outlook
Acid
reflux usually doesn’t cause complications, but continuous insult to the tissue
of esophagus by acid in uncontrolled condition may lead to serious
complications including:
Esophageal
Strictures:
Narrowing
of the esophagus and formation of scar tissue due to tissue damage. This
narrows the pathway for food and water to travel through and can cause
difficulty in swallowing.
Barrett’s
Esophagus:
These
precancerous changes to the lining of the esophagus are caused by continuous
damage by the acid in the stomach. Barretts esophagus increases the risk of
esophageal cancer.
Esophagitis:
Swelling
and inflammation of the esophagus caused by irritation of stomach acid. Esophagitis
may involve bleeding and ulceration.
Asthma:
Asthma
and related complications can be made worse. This is because acid reflux is
linked to chronic cough and breathing problems.
Dental
Problems:
Tooth
decay, enamel erosion, gum disease, and weakening of cavities may occur.