Gastroesophageal reflux, also known as acid reflux, occurs when the stomach contents reflux or back up into the esophagus and/or mouth.
Dr Dennis Khoo Yeap Teng
Consultant Gastroenterologist, Hepatologist & Physician
MBBS (Malaya), MRCP (UK), MRCPS (Glasgow), AM (Mal),
Fellowship in Gastroenterology, Hepatology & Advanced Endoscopy (MOH), MAGA (USA), MACG (USA), National Gastroenterolgy and Endoscopy Trainer (MOH)
Tropicana Medical Centre
Reflux is a normal process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause bothersome symptoms or complications.
In contrast, people with gastroesophageal reflux disease (GERD) experience bothersome symptoms as a result of the reflux. Symptoms can include heartburn, regurgitation, vomiting, and difficulty or pain with swallowing. The reflux of stomach acid can adversely affect the vocal cords causing hoarseness or even be inhaled into the lungs (called aspiration).
What Is Gastroesophageal Reflux?
When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure that is approximately 26cm long and 2.5cm wide in adults. The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.
At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter (LES). After swallowing, the LES relaxes to allow food to enter the stomach and then contracts to prevent the back-up of food and acid into the esophagus.
However, sometimes the LES is weak or becomes relaxed because the stomach is distended, allowing liquids in the stomach to wash back into the esophagus. This happens occasionally in all individuals. Most of these episodes occur shortly after meals, are brief, and do not cause symptoms. Normally, acid reflux should occur only rarely during sleep.
Acid reflux — Acid reflux becomes gastroesophageal reflux disease (GERD) when it causes bothersome symptoms or injury to the esophagus. The amount of acid reflux required to cause GERD varies.
In general, damage to the esophagus is more likely to occur when acid refluxes frequently, the reflux is very acidic, or the esophagus is unable to clear away the acid quickly. The most common symptoms associated with acid reflux are heartburn, regurgitation, chest pain, and trouble swallowing. The treatments of GERD are designed to prevent one or all of these symptoms from occurring.
Hiatus hernia — the diaphragm is a large flat muscle at the base of the lungs that contracts and relaxes as a person breathes in and out. The esophagus passes through an opening in the diaphragm called the diaphragmatic hiatus before it joins with the stomach.
Normally, the diaphragm contracts, which improve the strength of the LES, especially during bending, coughing, or straining. If there is a weakening in the diaphragm muscle at the hiatus, the stomach may be able to partially slip through the diaphragm into the chest, forming a sliding hiatus hernia.
The presence of a hiatus hernia makes acid reflux more likely. A hiatus hernia is more common in people over age 50. Obesity and pregnancy are also contributing factors. The exact cause is unknown but may be related to the loosening of the tissues around the diaphragm that occurs with advancing age. There is no way to prevent a hiatus hernia.
Acid Reflux Symptoms
People who experience heartburn at least two to three times a week may have gastroesophageal reflux disease, or GERD. The most common symptom of GERD, heartburn is experienced as a burning sensation in the centre of the chest, which sometimes spreads to the throat; there also may be an acid taste in the throat. Other symptoms of reflux maybe surprising and include:
- Stomach pain
- Non-burning chest pain
- Difficulty swallowing (called dysphagia), or food getting stuck
- Painful swallowing
- Persistent laryngitis/hoarseness
- Persistent sore throat
- Chronic cough, new onset asthma, or asthma only at night
- Regurgitation of foods/fluids; taste of acid in the throat
- Sense of a lump in the throat
- Worsening dental disease
- Recurrent lung infections (called pneumonia)
- Chronic sinusitis
- Waking up with a choking sensation
When to seek help — the following signs and symptoms may indicate a more serious problem, and should be reported to a healthcare provider immediately:
- Difficulty or pain with swallowing (feeling that food gets “stuck”)
- Unexplained weight loss
- Chest pain
- Choking
- Bleeding (vomiting blood or dark-coloured stools)
Acid Reflux Complications
The vast majority of patients with gastroesophageal reflux disease will not develop serious complications, particularly when reflux is adequately treated. However, a number of serious complications can arise in patients with severe gastroesophageal reflux disease.
Ulcers — Ulcers can form in the esophagus as a result of burning from stomach acid. In some cases, bleeding occurs. You may not be aware of bleeding.
Stricture — Damage from acid can cause the esophagus to scar and narrow, causing a blockage (stricture) that can cause food or pills to get stuck in the esophagus. The narrowing is caused by scar tissue that develops as a result of ulcers that repeatedly damage and then heal in the esophagus.
Lung and throat problems — Some people reflux acid into the throat, causing inflammation of the vocal cords, a sore throat, or a hoarse voice. The acid can be inhaled into the lungs and cause a type of pneumonia (aspiration pneumonia) or asthma symptoms. Chronic acid reflux into the lungs may eventually cause permanent lung damage, called pulmonary fibrosis or bronchiectasis.
Barrett’s esophagus — Barrett’s esophagus occurs when the normal cells that line the lower esophagus (squamous cells) are replaced by a different cell type (intestinal cells). This process usually results from repeated damage to the esophageal lining, and the most common cause is longstanding gastroesophageal reflux disease. The intestinal cells have a small risk of transforming into cancer cells.
Esophageal cancer — A major risk factor for adenocarcinoma of the oesophagus is Barrett’s esophagus, discussed above. However, only a small percentage of people with GERD will develop Barrett’s esophagus and an even smaller percentage will develop adenocarcinoma.
Reflux Treatment
Gastroesophageal reflux disease is treated according to its severity.
Mild symptoms — Initial treatments for mild acid reflux include dietary changes and using non-prescription medications like antacid.
Lifestyle changes — Weight loss – Losing weight may help people who are overweight to reduce acid reflux.
- Raise the head of the bed six to eight inches – Although most people only have heartburn for the two- to three-hour period after meals, some wake up at night with heartburn. People with nighttime heartburn can elevate the head of their bed, which raises the head and shoulders higher than the stomach, allowing gravity to prevent acid from refluxing. Raising the head of the bed can be done with blocks of wood under the legs of the bed or a foam wedge under the mattress. Several manufacturers have developed commercial products for this purpose. However, it is not helpful to use additional pillows; this can cause an unnatural bend in the body that increases pressure on the stomach, worsening acid reflux.
- Avoid acid reflux-inducing foods – Some foods also cause relaxation of the lower esophageal sphincter, promoting acid reflux. Excessive caffeine, chocolate, alcohol, peppermint, and fatty foods may cause bothersome acid reflux in some people.
- Quit smoking – Saliva helps to neutralise refluxed acid, and smoking reduces the amount of saliva in the mouth and throat. Smoking also lowers the pressure in the lower esophageal sphincter and provokes coughing, causing frequent episodes of acid reflux in the esophagus. Quitting smoking can reduce or eliminate symptoms of mild reflux.
- Avoid large and late meals – Lying down with a full stomach may increase the risk of acid reflux. By eating three or more hours before bedtime, reflux may be reduced. In addition, eating smaller meals may prevent the stomach from becoming overdistended, which can cause acid reflux.
- Avoid tight fitting clothing – At minimum, tight-fitting clothing can increase discomfort, but it may also increase pressure in the abdomen, forcing stomach contents into the esophagus.
Antacids — Antacids are commonly used for short-term relief of acid reflux. However, the stomach acid is only neutralised very briefly after each dose, so they are not very effective.
Histamine antagonists — the histamine antagonists reduce production of acid in the stomach. However, they are somewhat less effective than proton pump inhibitors (PPIs).
Example of histamine antagonists available is ranitidine (Zantac),
Moderate to severe symptoms — Patients with moderate to severe symptoms of acid reflux, complications of gastroesophageal reflux disease, or mild acid reflux symptoms that have not responded to the lifestyle modifications and the medications described above usually require treatment with prescription medications. Most patients are treated with a proton pump inhibitor.
Proton pump inhibitors — PPIs include omeprazole (omesec, losec), esomeprazole (Nexium), lansoprazole (Prevacid), dexlansoprazole (dexilant), pantoprazole (controloc), and rabeprazole (pariet), which are stronger and more effective than the H2 antagonists.
Once the optimal dose and type of PPI is found, you will probably be kept on the PPI for approximately eight weeks. Depending upon your symptoms after eight weeks, the medication dose may be decreased or discontinued. If symptoms return within three months, long-term treatment is usually recommended. If symptoms do not return within three months, treatment may be needed only intermittently. The goal of treatment for GERD is to take the lowest possible dose of medication that controls symptoms and prevents complications.
Proton pump inhibitors are safe, although they may be expensive, especially if taken for a long period of time. Long-term risks of PPIs may include an increased risk of gut infections, or reducedabsorption of minerals and nutrients. In general, these risks are small. However, even a small risk emphasizes the need to take the lowest possible dose for the shortest possible time.
