Acid Reflux: Causes, Symptoms and Treatments
October 15, 2016 at 10:34 AM
Acid reflux is one of the top health-related internet search queries, a very common symptom of burning pain felt internally around the lower chest area, caused by stomach acid flowing back up into the food pipe.
Gastroesophageal reflux disease (GERD, or GORD for gastro-oesophageal reflux disease) is acid reflux more than twice a week.
Use this page to learn what causes acid reflux and gastroesophageal reflux disease. Also get an overview of symptoms, and how the condition is diagnosed. We outline the treatment options available for the management of the condition, and how lifestyle measures may have preventive benefit.
Contents of this article:
1. What is acid reflux?
2. What causes acid reflux?
3. Signs and symptoms of acid reflux
4. Tests and diagnosis
5. Treatment and prevention of acid reflux
6. Over-the-counter remedies for acid reflux
7. Other options
8. Prevention of acid reflux through lifestyle control
9. Risks from long-term GERD
You will also see introductions at the end of some sections to any recent developments that have been covered by MNT's news stories. Also, look out for links to information about related conditions.
What is acid reflux?
Acid reflux is when some of the acid content of the stomach flows up into the esophagus - into the gullet, which moves food down from the mouth.
The stomach contains a strong acid, hydrochloric acid, to help with the efficient digestion of food and to protect against undesirable microbes such as bacteria.
The lining of the stomach is specially adapted to produce this acid, and also to protect the digestive organ against its own corrosive secretion, but the higher gut is not protected from this acid.
A ring of muscle - the gastroesophageal sphincter - normally protects the esophagus from the contents of the stomach by acting as a valve that lets food into the stomach but not back up into the esophagus. When this valve fails and stomach contents are regurgitated into the esophagus, the symptoms of acid reflex are felt, such as heartburn. This is also known as pyrosis or acid indigestion.
Exact figures vary but acid reflux is considered very common, and diseases resulting from acid reflux are the most common gut complaint seen by US hospital departments.
The American College of Gastroenterology says that over 60 million Americans experience heartburn at least once a month, and at least 15 million as often as daily.
Gastroesophageal reflux disease has the highest burden in western countries, affecting an estimated 20-30% of the population. Americans are especially prone to GERD, likely due to a higher prevalence of several lifestyle risk factors, which are explored below.
Recent developments on reflux disease statistics
Acid reflux 50% more common than ten years ago. This study, published in the journal Gut in December 2011, yielded detailed sets of statistics about changes in the prevalence of acid reflux symptoms and disease in the Norwegian population.
What causes acid reflux?
We all may experience acid reflux occasionally, often associated with certain food and drink. Recurrent acid reflux that leads to disease has other causes and risk factors, and is termed gastroesophageal reflux disease (GERD or GORD).
Gastroesophageal reflux disease is seen in people of all ages, sometimes for unknown reasons (idiopathic). Often the cause is attributable to a lifestyle factor, but it can also be due to causes that cannot always be prevented.
One such cause of GERD is a hiatal (or hiatus) hernia. This is an anatomical abnormality where a hole in the diaphragm allows the upper part of the stomach to enter the chest cavity, sometimes leading to GERD.
Pregnancy is also sometimes a cause of acid reflux due to extra pressure being placed on the internal organs.
Other risk factors are more easily controlled and often directly linked to modifiable lifestyle or dietary issues, including:
- Smoking (active or passive)
- High intake of table salt
- Low dietary fibre intake
- Low levels of hysical exercise
- Medications, including drugs for asthma, calcium-channel blockers, antihistamines, painkillers, sedatives, and antidepressants.
Individuals may report an association with certain food and drinks but research suggests there is not any link between gastroesophageal reflux disease and intake of alcohol, coffee or tea.
This animation from YouTube, produced by the Mayo Clinic, shows how stomach acid looks in the digestive system, and the action of the gastroesophageal sphincter (valve) as it allows reflux into the esophagus.
Signs and symptoms of acid reflux
Acid reflux, whether it is a harmless, isolated episode of the sort we all experience at some point, or the persistent problem of gastroesophageal reflux disease, usually produces the same main symptom:2,4,7
Heartburn is a discomfort - happening in the esophagus and felt behind the breastbone area - that takes the form of a burning sensation and which tends to worsen when the person lies down or bends over.2 It can last for several hours and also tends to worsen after eating food.
The burning pain may move up toward the neck and throat as stomach fluid can reach the back of the throat in some cases, producing a bitter or sour taste.
We all experience heartburn occasionally, due to simple acid reflux, but if this occurs regularly - two or more times a week - it is termed gastroesophageal reflux disease, or GERD for short. GERD can also be signalled by other symptoms, including:
- Dry, persistent cough
- Asthma and recurrent pneumonia
- Throat problems - soreness, hoarseness, or laryngitis (voice box inflammation)
- Difficulty or pain when swallowing
- Chest or upper abdominal pain
- Dental erosion
- Bad breath.
Tests and diagnosis
The first port of call for someone experiencing frequent acid reflux symptoms is the family doctor, who may refer on to a specialist in gut medicine, a gastroenterologist.
Gastroesophageal reflux disease is often diagnosed simply by finding no improvement in heartburn symptoms in response to lifestyle changes and acid reflux medication.
Gastroenterologists may also arrange the following investigations:
- Endoscopy (camera imaging)
- Biopsy (taking a tissue sample for laboratory analysis)
- Barium X-ray (imaging the esophagus, stomach and upper duodenum after swallowing a chalky liquid that helps provide contrast on images)
- Esophageal manometry (pressure measurement of the esophagus)
- Impedance monitoring (measuring rate of fluid movement along the esophagus)
- pH monitoring (acidity testing).
Treatment and prevention of acid reflux
The main treatment option for people who repeatedly experience acid reflux in gastroesophageal reflux disease is a class of drugs known as proton-pump inhibitors (PPIs for short).
The mode of action of proton-pump inhibitors is to decrease acid production and thereby reduce the potential for damage caused by acid reflux.
Here is the full list of proton-pump inhibitors available on prescription in the US (brand names given followed by generic names, 2014):
- Aciphex (rabeprazole)
- Dexilant (dexlansoprazole)
- Nexium (esomeprazole)
- Prevacid (lansoprazole)
- Prilosec (omeprazole; also available in pharmacies without prescription)
- Protonix (pantoprazole)
- Zegerid (immediate-release omeprazole with sodium bicarbonate).
Proton-pump inhibitors are generally safe and effective, but like any prescription drug, they are not appropriate for all people with reflux disease and can cause side-effects, such as malabsorption issues leading to nutrient deficiencies.
PPIs are blockbuster drugs - prescribed to millions and earning huge sums for pharmaceutical firms because of their common use.
Proton-pump inhibitors have superseded earlier drug therapies that were used for gastroesophageal reflux disease - H2 blockers (also known as H2-receptor antagonists). These were the first blockbuster drugs of modern medicine - Zantac (ranitidine), for example, was the drug that caused GlaxoSmithKline to become a key pharmaceutical giant.
Over-the-counter remedies for acid reflux
For people who experience heartburn or indigestion infrequently, perhaps in association with occasional food and drink triggers, treatments to reduce the acidity of the stomach contents are available without prescription from pharmacies (over-the-counter products).
These liquid and tablet formulations are called antacids and there are dozens of brands available, all with similar effectiveness. They may not work for everyone, and any need for regular use should be discussed with a doctor.
Antacids provide rapid but short-term relief by buffering the acidity through simple chemical reaction with the stomach contents (they do not act on acid-producing cells of the stomach lining).
They contain chemical compounds such as calcium carbonate, sodium bicarbonate, aluminum, and magnesium hydroxide, and can also inhibit nutrient absorption, leading to deficiencies over time.
Alginate drugs such as Gaviscon
Gaviscon is probably the best known heartburn therapy, available over the counter at pharmacies. It has a different mode of action than antacid drugs, containing alginic acid. Alginate drugs such as this brand vary slightly in composition, but they usually also contain an antacid.
The alginic acid works by creating a mechanical barrier against the stomach acid, forming a foamy gel that sits at the top of the gastric pool itself. Any reflux is then relatively harmless as it consists of alginic acid and not damaging stomach acid
The active ingredient alginate is found naturally in brown algae.
The main options for the management of gastroesophageal reflux disease have been covered above. A long list of other therapies is available, however, with one pharmacological review listing the following additional options: sucralfate acid suppressants, potassium-competitive acid blockers, transient lower esophageal sphincter relaxation (TLESR) reducers, GABA(B) receptor agonist, mGluR5 antagonist, prokinetic agents, pain modulators, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and the serotonin-norepinephrine reuptake inhibitor theophylline.
In rare cases, gastroesophageal reflux disease that is severe and unresponsive to medical treatment may warrant surgical intervention in the form of a procedure called fundoplication - the National Institutes of Health has detailed information about this operation at Medline.
Recent developments in surgical treatment
New GERD device offered at Mayo Clinic. There was news in 2012 that patients who had persistent gastroesophageal disease (GERD) that did not respond to medical treatment could try a new surgical option developed by American specialists. It is a ring, powered by magnets, that mechanically strengthens the gastroesophageal sphincter.
Prevention of acid reflux through lifestyle control
As discussed above, lifestyle can play a large part in the development of acid reflux-related problems, and changes to lifestyle or behavior can prevent or improve symptoms.
One summary of the actions patients might take has been compiled by the American Gastroenterological Association. This includes advice for patients with troublesome irritation to keep a diary, so that they may find any links to lifestyle factors.
The American Gastroenterological Association also offers the following list of things to try to see if symptoms resolve:
- Avoid food, drinks and medicines that you find to be associated with heartburn irritation
- Eat smaller meals
- Do not lie down for two to three hours after a meal
- Lose weight if overweight or obese
- Avoid increased pressure on your abdomen, such as from tight belts or doing sit-up exercises
- Stop smoking.
There is also some suggestion that eradication of infection with Helicobacter pylori can lead to the development of gastroesophageal reflux disease, although this has only been seen so far in Asian countries where the prevalence of H. pylori infection is higher than in western countries.
Recent developments in acid reflux and lifestyle
Lifestyle training may reduce pain of heartburn. British researchers found benefit from a lifestyle educational program delivered in four once-weekly 1.5-hour sessions. The study published by general practitioners in 2010 encouraged participants to record their symptoms, look at their diet, learn about managing stress, set goals for themselves, and identify their three biggest problems relating to their acid reflux condition.
Risks from long-term GERD
It is important to address persistent problems with gastroesophageal reflux disease as long-term untreated acid reflux can lead to serious complications including an increased risk of cancer.
Long-term, continual exposure to stomach acid can damage the esophagus, leading to:
- Esophagitis - where the lining of the esophagus is inflamed, causing irritation, bleeding and ulceration in some cases
- Strictures - where the damage caused by stomach acid leads to scar development and difficulties swallowing, with food getting stuck as it travels down the esophagus
- Barrett's esophagus - a serious complication where repeated exposure to stomach acid causes changes in the cells and tissue lining the esophagus replacing normal cells with those that resemble cells in the lower gastrointestinal tract. This is considered a premalignant condition.
Both esophagitis and Barrett's esophagus are associated with a higher risk of cancer.
Esophagitis may lead to precancerous changes in the pipe, and Barrett's esophagus carries a clear risk of lethal cancer for a small number of patients.
There was a landmark study published in the New England Journal of Medicine in 1999 that found a link between untreated acid reflux and cancer. Its conclusion reads as a stark warning against leaving acid reflux untreated for a long time:
"There is a strong and probably causal relation between gastroesophageal reflux and esophageal adenocarcinoma."