Acid Reflux Description:
Alternative Names: Peptic esophagitis; Reflux esophagitis; GERD; Heartburn - chronic
The esophagus, commonly called the food pipe, is a narrow muscular tube about nine-and-a-half inches long. It begins below the tongue and ends at the stomach. The esophagus is narrowest at the top and bottom; it also narrows slightly in the middle.
The esophagus consists of three basic layers:
- An outer layer of fibrous tissue.
- A middle layer containing smoother muscle.
- An inner membrane, which contains many tiny glands.
When a person swallows food, the esophagus moves it into the stomach through the action of wave-like muscle contractions, called peristalsis. In the stomach, the starch, fat, and protein in food are broken down by acid and various enzymes, notably hydrochloric acid and pepsin. The lining of the stomach has a thin layer of mucus that protects it from these fluids.
If acid and enzymes back up into the esophagus, however, its lining offers only a weak defense against these substances. Instead, several other factors protect the esophagus. The most important structure protecting the esophagus may be the lower esophageal sphincter (LES). The LES is a band of muscle around the bottom of the esophagus, where it meets the stomach.
After a person swallows, the LES opens to let food enter the stomach. It then closes immediately to prevent regurgitation of the stomach contents, including gastric acid. The LES maintains this pressure barrier until food is swallowed again.
If the pressure barrier is not enough to prevent regurgitation and acid backs up (reflux), peristaltic action of the esophagus serves as an additional defense mechanism, pushing the backed-up contents back down into the stomach.
Gastroesophageal reflux disease (GERD) is a condition in which acids from the stomach flow back up into the esophagus (an action called reflux). Reflux occurs if the muscular actions in the esophagus or other protective mechanisms fail. Although acid is a primary factor in damage caused by GERD, other products of the digestive tract, including pepsin and bile, can also be harmful.
GERD is a chronic condition. Once it begins, it usually is life-long. If there is injury to the lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the esophagus has healed with treatment and treatment is stopped, the injury will return in most patients within a few months. Once treatment for GERD is begun, therefore, it usually will need to be continued indefinitely although it is argued that in some patients with intermittent symptoms and no esophagitis, treatment can be intermittent and done only during symptomatic periods.
In fact, the reflux of the stomach's liquid contents into the esophagus occurs in most normal individuals. One study found that reflux occurs as frequently in normal individuals as in patients with GERD. In patients with GERD, however, the refluxed liquid contains acid more often, and the acid remains in the esophagus longer. It has also been found that liquid refluxes to a higher level in the esophagus in patients with GERD than normal individuals.
As is often the case, the body has ways (mechanisms) to protect itself from the harmful effects of reflux and acid. For example, most reflux occurs during the day when individuals are upright. In the upright position, the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity. In addition, while individuals are awake, they repeatedly swallow, whether or not there is reflux. Each swallow carries any refluxed liquid back into the stomach. Finally, the salivary glands in the mouth produce saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva travels down the esophagus. The bicarbonate neutralizes the small amount of acid that remains in the esophagus after gravity and swallowing have removed most of the liquid.
Gravity, swallowing, and saliva are important protective mechanisms for the esophagus, but they are effective only when individuals are in the upright position. At night during sleep, gravity is not in effect, swallowing stops, and the secretion of saliva is reduced. Therefore, reflux that occurs at night is more likely to result in acid remaining in the esophagus longer and causing greater damage to the esophagus.
Certain conditions make a person susceptible to GERD. For example, GERD can be a serious problem during pregnancy. The elevated hormone levels of pregnancy probably cause reflux by lowering the pressure in the lower esophageal sphincter (see below). At the same time, the growing fetus increases the pressure in the abdomen. Both of these effects would be expected to increase reflux. Also, patients with diseases that weaken the esophageal muscles (see below), such as scleroderma or mixed connective tissue diseases, are more prone to develop GERD.
There are several ways to approach the evaluation and management of GERD. The approach depends primarily on the frequency and severity of symptoms, the adequacy of the response to treatment, and the presence of complications.
Heartburn is the primary symptom of GERD. It is a burning sensation that spreads up from the stomach to the chest and throat. Heartburn is most likely to occur in connection with the following activities:
Patients with nighttime GERD, a common problem, tend to feel more severe pain than those whose symptoms occur at other times of the day.
The severity of heartburn does not necessarily indicate actual injury to the esophagus. For example, Barrett's esophagus, which causes precancerous changes in the esophagus, may only trigger a few symptoms, especially in elderly people. On the other hand, people can have severe heartburn but suffer no damage in their esophagus.
Up to half of GERD patients have dyspepsia, a syndrome that consists of the following:
- Eating a heavy meal.
- Bending over.
- Lying down, particularly on the back.
Regurgitation is the feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and can be experienced as a "wet burp." Uncommonly, it may come out forcefully as vomit.
Chest Sensations or Pain: Patients may have the sensation that food is trapped behind the breastbone. Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions, such as angina and heart attack.
Symptoms in Children: Typical symptoms in infants include frequent regurgitation, irritability, arching the back, choking or gagging, and resisting feedings.
Causes and Risk factors of acid reflux:
Factors That May Cause GERD: Some people are born with a naturally weak lower esophageal sphincter (LES). For others, however, certain lifestyles, medications, activities or food choices may be the contributing factor.
- Pain and discomfort in the upper abdomen
- A feeling of fullness in the stomach.
- Nausea after eating.
- People without GERD can also have dyspepsia.
Genetic Factors: About 30 - 40% of reflux may be hereditary. An inherited risk exists in many cases of GERD, possibly because of inherited muscular or structural problems in the stomach or esophagus. Genetic factors may play an especially strong role in susceptibility to Barrett's esophagus, a precancerous condition caused by very severe GERD.
Other Conditions Associated with GERD: Crohn's disease is a chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus. Other disorders that may contribute to GERD include diabetes, any gastrointestinal disorder (including peptic ulcers), lymphomas, and other types of cancer.
Some of the risk factors of GERD are as follows:
- Alcohol Use: Alcohol has mixed effects on GERD. It relaxes the lower esophageal sphincter (LES) muscles and, in high amounts, may irritate the mucous membrane of the esophagus. All alcoholic beverages increase stomach acid levels. A combination of heavy alcohol use and smoking even increases the risk for esophageal cancer. Small amounts of alcohol, however, may actually protect the mucosal layer.
- Smoking: Smoking causes the lower esophageal sphincter (LES) at the top of the stomach to relax.
- Lying down or bending over from the waist.
- Snacking before bedtime.
- Tight clothing (around the waist).
- Vigorous exercise.
- Medications: There are dozens of nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin, ibuprofen (Motrin, Advil, Nuprin, Rufen), and naproxen (Aleve) and many prescription agents that also may contribute to heartburn or GERD. A person with GERD who takes the occasional aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) will not necessarily experience adverse effects. This is especially true if there are no risk factors or indications of ulcers. Acetaminophen (Tylenol) is a good alternative for those who want to relieve mild pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are being studied for protection against Barrett's esophagus. Newer nonsteroidal anti-inflammatory drugs (NSAIDs) called COX-2 inhibitors may prove to be cancer protective in these patients without producing GERD. They include celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra).
Diagnosis of acid reflux:
A physician can usually diagnose GERD if the patient finds relief from persistent heartburn and acid regurgitation after taking antacids for short periods of time. If the diagnosis is uncertain but the physician still suspects GERD, a drug trial using a proton-pump inhibitor (PPI) medication, such as omeprazole (Prilosec) identifies 80 - 90% of people with the condition. This class of medication blocks stomach acid secretion.
Laboratory or more invasive tests, including endoscopy, may be required if:
The diagnosis is still uncertain.
Symptoms are not typical.
Barrett's esophagus is suspected.
Complications, such as signs of bleeding or difficulty swallowing, are present.
Some of these tests are described below.
Barium Swallow Radiograph: A barium swallow radiograph (x-ray) is useful for identifying structural abnormalities and erosive esophagitis. For this test, the patient drinks a solution containing barium, and then x-rays of the digestive tract are taken. This test can show stricture, active ulcer craters, hiatal hernia, erosion, or other abnormalities. However, it cannot reveal mild irritation.
Upper Endoscopy: Upper endoscopy, also called esophagogastroduodenoscopy or panendoscopy, is more accurate than a barium swallow radiograph. It is also more invasive and expensive. It is widely used in GERD for identifying and grading severe esophagitis, monitoring patients with Barrett's esophagus, or when other complications of GERD are suspected. Upper endoscopy is also used as part of various surgical techniques.
Until recently, experts recommended screening with endoscopy for Barrett's esophaguus and esophageal cancer at least once in a lifetime for patients with chronic GERD. However, new guidelines from the American Gastroenterological Association do not recommend endoscopy screening because there is no evidence that it can improve survival.
If a patient has moderate-to-severe GERD symptoms and the procedure reveals injury in the esophagus, usually no further tests are needed to confirm a diagnosis. The test is not foolproof, however. A visual view misses about half of all esophageal abnormalities.
Capsule Endoscopy: In this test, the patient swallows a small capsule containing a tiny camera. Then, a series of color pictures are transmitted to a recording device where they can be downloaded and interpreted by a doctor. The entire procedure takes 20 minutes. The capsule is naturally passed through the digestive system within 24 hours. A newer technique has a string attached to the capsule for retrieval. Capsule endoscopy may provide a more attractive and less invasive alternative to traditional endoscopy. However, while capsule endoscopy is useful as a screening device for diagnosing esophageal conditions such as GERD and Barrett's esophagus, traditional endoscopy is still required for gathering tissue samples or removing polyps.
pH Monitor Examination: The (ambulatory) pH monitor examination may be used to determine acid backup. It is useful when endoscopy has not detected damage to the mucus lining in the esophagus, but GERD symptoms are present. pH monitoring may be used when patients have not found relief from medicine or surgery. The traditional trans-nasal catheter diagnostic procedure involved inserting a tube through the nose and down to the esophagus. The tube was left in place for 24 hours. This test was irritating to the throat, and uncomfortable and awkward for most patients.
A new method known as the Bravo pH test uses a small capsule-sized data transmitter that is temporarily attached to the wall of the esophagus during endoscopy. The capsule records pH levels and transmits these data to a pager-sized receiver the patient wears. Patients can maintain their usual diet and activity schedule during the 24 - 48-hour monitoring period. After a few days, the capsule detaches from the esophagus, passes through the digestive tract, and is eliminated through a bowel movement.
Manometry: Manometry is a technique that measures muscular pressure. It uses a tube containing various openings, which is placed through the esophagus. As the muscular action of the esophagus puts pressure on the tube in various locations, a computer connected to the tube measures this pressure. Manometry is useful for the following situations:
Blood and Stool Tests: Stool tests may show traces of blood that are not visible without a microscope. Blood tests for anemia should be performed if bleeding is suspected.
Bernstein Test: For patients with chest pain in which the diagnosis is uncertain, a procedure called the Bernstein test may be helpful, although it is rarely used. A tube is inserted through the patient's nasal passage. Solutions of hydrochloric acid and saline (salt water) are administered separately into the esophagus. A diagnosis of GERD is established if the acid infusion causes symptoms and the saline solution does not.
Treatment of acid reflux:
- Peptic Ulcer.
- Connective tissue disorders such as scleroderma.
- Zollinger-Ellison Syndrome.
- Overweight, cigarette smoking and aging.
Acid suppression continues to be the mainstay for treating GERD. The aim of drug therapy is to reduce the amount of acid and improve any abnormalities in muscle function of the lower esophageal sphincter, esophagus, or stomach.
Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes, over-the-counter medications, and antacids.
The two major treatment options are known as the step-up and step-down approaches:
Step-up: With a step-up drug approach the patient first tries an H2 blocker drug, which is available over the counter. These drugs include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). If the condition fails to improve, therapy is "stepped up" to the more powerful proton-pump inhibitors, usually omeprazole (Prilosec).
Step-down: A step-down approach first uses a more potent drug, most often a proton-pump inhibitor (PPI), such as omeprazole (Prilosec). When patients have been symptom-free for 2 months or longer, they are then "stepped down" to a half-dose. If symptoms do not come back, the drug is stopped. If symptoms return, the patient is put on high-dose H2 blockers. Some physicians argue that the step-down approach should be used for most patients with moderate-to-severe GERD.
If neither approach relieves symptoms, the physician should look for other conditions. Endoscopy and other tests might be used to confirm GERD and rule out other disorders, as well as evaluate when treatment is not working. In some cases, bile, not acid, may be responsible for symptoms, so acid-reducing or blocking agents would not be helpful.
Managing acid reflux in Infancy and Childhood:
- During and after feeding, infants should be positioned vertically and burped frequently.
- If a baby with GERD is fed formula, the mother should ask the doctor how to thicken it in order to prevent splashing up from the stomach.
- Parents of infants with GERD should discuss the baby's sleeping position with their pediatrician. The seated position should be avoided, if possible. Experts strongly recommend that all healthy infants sleep on their backs to help prevent sudden infant death syndrome (SIDS). For babies with GERD, however, lying on the back may obstruct the airways. If the physician recommends that the baby sleeps on his stomach, the parents should be sure that the infant's mattress is very firm, possibly tilted up at the head, and that there are no pillows. The baby's head should be turned so that the mouth and nose are completely unobstructed. Carefully watch children who are placed on their stomach.
- Food allergies may trigger GERD in children, parents may want to discuss a dietary plan with their physician that starts the child on formulas using non-allergenic proteins, and then incrementally adds other foods until symptoms are triggered.
- Proton-pump inhibitors (PPIs), such as omeprazole (Prilosec) and lansoprazole (Prevacid), are drugs that suppress the production of stomach acid. The FDA has approved the proton-pump inhibitor (PPI) esomeprazole (Nexium) for the short-term treatment of GERD in children ages 1 - 11. In studies, treatment with Nexium once a day for eight weeks was safe and well tolerated in children. The most common side effects were headache, diarrhea, abdominal pain, nausea, gas, constipation, dry mouth, and sleepiness.
- Surgical fundoplication involves wrapping the upper curve of the stomach (fundus) around the esophagus. The goal of this surgical technique is to strengthen the LES. Until recently, surgery was the primary treatment for children with severe complications from GERD because older drug therapies had severe side effects, were ineffective, or had not been designed for children. However, with the introduction of PPIs, some children may be able to avoid surgery. Surgical fundoplication can be performed laparoscopically through small incisions. Weakening of the LES over the long-term occurs with children as well as adults.
Surgery: Surgery may be needed in certain circumstances:
If lifestyle changes and drug treatments have failed If patients cannot tolerate medication In patients who have other medical complications In younger people with chronic GERD, who face a lifetime of expense and inconvenience with maintenance drug treatment. Some physicians are recommending surgery as the treatment of choice for many more patients with chronic GERD, particularly because minimally invasive surgical procedures are becoming more widely available, and only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than was previously believed, and the long-term safety of using medication for acid suppression is still uncertain.
Nevertheless, anti-GERD procedures have many complications and high failure rates. As with medications, current surgical procedures cannot cure GERD. About 15% of patients still require anti-GERD medications after surgery. Furthermore, about 40% of surgical patients are at risk for new symptoms after surgery (such as gas, bloating, and trouble swallowing), with most side effects occurring more than a year after surgery. Finally, evidence now suggests that surgery does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. New procedures may improve current results, but at this time patients should consider surgical options very carefully with both a surgeon and their primary doctor.
Medicine and medications:
Antacids neutralize acids in the stomach, and are the drugs of choice for mild GERD symptoms. Although all antacids work equally well, it is generally believed that liquid antacids work faster and are more potent than tablets. Antacids can interact with a number of drugs in the intestines by reducing their absorption. These drugs include tetracycline, ciprofloxacin (Cipro), propranolol (Inderal), captopril (Capoten), and H2 blockers. Interactions can be avoided by taking the drugs 1 hour before, or 3 hours after taking the antacid. Long-term use of nearly any antacid increases the risk for kidney stones.
Proton-Pump Inhibitors: Proton-pump inhibitors (PPIs) suppress the production of stomach acid and work by inhibiting the molecule in the stomach glands that is responsible for acid secretion (the gastric acid pump). Recent guidelines indicate that PPIs should be the first drug treatment, because they are more effective than H2 blockers. Once symptoms are controlled, patients should receive the lowest effective dose of PPIs.
The standard PPI has been omeprazole (Prilosec), which is now available over the counter without a prescription. Newer prescription oral PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), and pantoprazole (Protonix). Side effects are uncommon but may include headache, diarrhea, constipation, nausea, and itching.
H2 blockers: H2 blockers are available over the counter and relieve symptoms in about half of GERD patients. It takes 30 - 90 minutes for them to work, but the benefits last for hours. People usually take the drugs at bedtime. Some people may need to take them twice a day.
Medications that Protect the Mucus Lining (Sucralfate): Sucralfate (Carafate) protects the mucus lining in the gastrointestinal tract. It seems to work by sticking to an ulcer crater and protecting it from the damaging effects of stomach acid and pepsin. Sucralfate may be helpful for maintenance therapy in people with mild-to-moderate GERD. Other than constipation, the drug has few side effects. Sucralfate interacts with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline.
Anti-Spasm Drugs to Prevent Acid and Non-Acid Reflux: Most drugs used for GERD have no effect on non-acid reflux, such as the backup of bile. Baclofen is commonly used to reduce muscle spasms. Studies are now showing that it can reduce both acid and non-acid reflux episodes and increase LES pressure, an important factor for preventing acid backup.
If you suspect that one of your medications may be causing heartburn, talk to your doctor.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.