Acid Reflux

Gastroesophageal reflux disease (GERD) is a chronic medical condition caused by the flow of contents from the stomach upwards into the esophagus resulting in both symptoms and complications. The most common symptoms of GERD are heartburn and regurgitation. Heartburn is a burning sensation in the chest behind the breastbone. Regurgitation is a feeling of fluid or food coming up into the chest. Many people experience both symptoms; however, some patients can have one without the other.

GERD is one of the most common gastrointestinal diseases. It is thought that up to 20% of the US population has GERD. Almost everyone will experience heartburn at some point, especially after a heavy meal. However, GERD is defined as frequent symptoms (two or more times a week) or when the esophagus suffers damage from reflux such as narrowing, erosions, or pre-cancerous changes. GERD is more common amongst the elderly, obese and pregnant women.

These terms are often used interchangeably, but they actually have very different meanings. GERD is the disease or diagnosis defined as regular symptoms caused by the flow of gastric contents into the esophagus. Heartburn is one of the symptoms of GERD. Acid reflux is the reason why patients have GERD. There is actually reflux that can be non-acidic that can be seen in GERD as well.

GERD is caused by the flow of gastric acid and bile into the esophagus. The stomach is designed to handle these fluids. When the gastric contents come into contact with the esophagus, it can produce the classic symptoms of heartburn and regurgitation. In addition, these fluids are toxic to the lining of the esophagus and can cause damage such as ulcers or even pre-cancerous changes such as Barrett’s esophagus.

GERD is almost never caused by the production of too much acid. It is caused by abnormal reflux of gastric contents into the esophagus. The body has multiple barriers to prevent gastric contents from refluxing into the esophagus, including a flap valve at the bottom of the esophagus, the breathing muscle (the diaphragm), and gravity. In GERD, certain foods, lifestyle habits, and anatomic issues (hiatal hernia) can weaken these barriers. Or can make a referral to lifestyle modifications section. Like see lifestyle medications for foods and lifestyle habits that can be addressed to treat GERD. Maybe insert a table for food items, lifestyle habits and treatment options. (caffeine, citrus/spicy foods, high fat foods, smoking, caffeine intake being overweight, etc.)

In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of over-the-counter medicines.

Lifestyle Modifications

• Avoid certain trigger foods and beverages: chocolate, coffee, peppermint, greasy or spicy foods, tomato products, and alcoholic beverages.
• Stop smoking. Tobacco may result in acid reflux and is one of the biggest risk factors for esophageal cancer.
• Weight loss if overweight. Excess abdominal fat is one of the biggest risk factors for heartburn.
• Wait at least 2-3 hours after eating before laying down to sleep. Gravity is one of our biggest protections against acid reflux. Because of that, keeping our head or bed elevated at an angle is also very helpful for nighttime symptoms.

Over-the-Counter Medications

There are a number of over the counter medicines available for treatment of occasional heartburn. These include medicines that neutralize acid in the stomach, medicines that block flow of fluids back into the stomach, and finally medicines that decrease the production of fluids in the stomach itself.

Recently a class of medications called proton pump inhibitors (PPI) became available over the counter. It is important to note that the dosage available over the counter may be different than the dosages available as a prescription.

Over-the-counter medications have a significant role in providing relief from heartburn and other occasional GI discomforts. More frequent episodes of heartburn or acid indigestion may be a symptom of a more serious condition that could worsen if not treated. If you are using an over-the-counter product more than twice a week, you should consult a physician who can confirm a specific diagnosis and develop a treatment plan with you, including the use of stronger medicines that are only available with a prescription.

GERD can result in serious complications including severe chest pain that can mimic a heart attack, esophageal stricture (a narrowing or obstruction of the esophagus), bleeding, or a pre-cancerous change in the lining of the esophagus called Barrett's esophagus.

When symptoms of heartburn are not controlled with lifestyle modifications or over-the-counter medicines are needed two or more times a week, you should see your doctor. You may have GERD and be at risk for complications of GERD.

Symptoms suggesting that serious damage may have already occurred include:

• difficulty swallowing or a feeling that food is trapped behind the chest.
• Bleeding: vomiting blood, or having tarry, black bowel movements.
• Choking: sensation of acid refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
• Weight Loss
• If you have any of these symptoms, you should speak to your doctor immediately

Treatment should be designed to eliminate symptoms, heal irritation of the esophagus and prevent the long-term complications of GERD. In most patients outside of significant lifestyle changes such as weight loss, GERD is a chronic disease. As such, long-term maintenance treatment to control symptoms and prevent complications may be necessary. Maintenance therapy will vary in individuals ranging from mere lifestyle modifications to prescription medication as treatment. The medicines are treatments and not cures.

All treatments are based on attempts to decrease the amount of acid that refluxes from the stomach back into the esophagus or make the refluxed material less irritating to the lining of the esophagus.

Lifestyle Modification

In order to decrease the amount of gastric contents that reach the esophagus, certain simple guidelines should be followed:

• Raise the Head of the Bed. Use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.
• Change Eating and Sleeping Habits. Avoid lying down for two hours after eating. Do not eat for at least two hours before bedtime. This decreases the amount of stomach acid available for reflux.
• Avoid Tight Clothing.
• Weight loss if overweight. Patients who are overweight are significantly more likely to have GERD compared to ideal body weight
• Change Your Diet. Avoid foods and medications that trigger GERD (fats, chocolate and caffeinated drinks) and foods that may irritate the damaged lining of the esophagus (citrus juice, tomato juice, and probably pepper).
• Both smoking and alcoholic beverages lower LES pressure, which contributes to acid reflux.

Medications for GERD

GERD can be improved with lifestyle changes but often requires medicines for complete management. If you are using over-the-counter medications two or more times a week, or are still having symptoms despite taking daily medicines, you need to see your doctor.

The main prescription medications to treat GERD include drugs called H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs). These medicines reduce the amount of acid produced in the stomach.

H2 Receptor Antagonists

Since the mid 1970's, acid suppression agents, known as H2 receptor antagonists or H2 blockers, have been used to treat GERD. H2 blockers improve the symptoms of heartburn and regurgitation.

H2 blockers are generally less expensive than proton pump inhibitors and can provide adequate initial treatment or serve as a maintenance agent in GERD patients with mild symptoms. Current treatment guidelines also recognize the appropriateness and in some cases desirability of using proton pump inhibitors as first-line therapy for some patients, particularly those with more severe symptoms or esophagitis on endoscopy. Proton pump inhibitors will be required to achieve effective long-term maintenance therapy in a significant percentage of heartburn/GERD patients.

Surgical management of GERD can be considered in patients who do not completely respond to medical management, patients who are unable to tolerate the medicines due to adverse reactions or in patients who do not want to take a chronic medicine. Surgical management prevents gastric reflux by strengthening the barrier between the stomach and the esophagus. There are a number of different surgical approaches to GERD. Consultation with both a gastroenterologist and a surgeon is recommended prior to such a decision. Additional testing is usually required.

A gastroenterologist is a physician who specializes in the diagnosis and management of disorders and conditions of the gastrointestinal tract. After completing medical school, they first complete a 3-year training (residency) in internal medicine. This is followed by a 3-4 year training (fellowship) specifically focused on conditions of the gastrointestinal tract.

Your doctor or gastroenterologist may wish to evaluate your symptoms with additional tests when it is unclear whether your symptoms are caused by acid reflux, or if you suffer from complications of GERD such as dysphagia (difficulty in swallowing), bleeding, choking, or if your symptoms fail to improve with prescription medications. Your doctor may decide to conduct one or more of the following tests.

Upper GI Series

For the upper GI series, you will be asked to swallow a liquid barium mixture. The radiologist then takes a series of pictures and videos to watch the barium as it travels down your esophagus and into the stomach.

You will be asked to move into various positions on the X-ray table while the radiologist watches the GI tract. Permanent pictures (X-ray films) will be made as needed.

Endoscopy

This test involves passing a small lighted flexible tube through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedatives. It is the best test to identify inflammation of the esophagus and pre-cancerous conditions of esophagus (Barrett's esophagus), or other complications of the esophagus.

Acid (pH) Testing

The diagnosis of GERD is often made based on physical and history alone. However occasionally direct measurement of the amount of acid/fluid refluxed into the esophagus is necessary to help diagnose and treat GERD. A pH test involves either placement of a small catheter through the nose into the esophagus or a small chip directly attached to the esophagus during endoscopy which can provide objective data about the the degree of acid reflux.

Atypical Symptoms

Besides heartburn and regurgitation, GERD can result in a number of other symptoms outside of the esophagus.

Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like heartburn and acid regurgitation. If your doctor says your chest pain is not coming from the heart, do not forget about the esophagus. On the other hand, if you have chest pain, you should not assume it is your esophagus until you have been evaluated for a potential heart cause by your physician.

Asthma: Acid reflux may aggravate asthma. Recent studies suggest that the majority of asthmatics have acid reflux. Clues that GERD may be worsening your asthma include: 1) asthma that appears for the first time during adulthood; 2) asthma that gets worse after meals, lying down or exercise; and 3) asthma that is mainly at night. Treatment of acid reflux may cure asthma in some patients and decrease the need for asthmatic medications in others.

Ear, Nose, and Throat Problems: Acid reflux may be a cause of chronic cough, sore throat, laryngitis with hoarseness, frequent throat clearing, or growths on the vocal cords. If these problems do not get better with standard treatments, think about GERD.

Peptic Stricture: This results from chronic acid injury and scarring of the lower esophagus. Patients complain of food sticking in the lower esophagus. Heartburn symptoms may actually lessen as the esophageal opening narrows down, preventing acid reflux. Stretching of the esophagus and proton pump inhibitor medication are needed to control and prevent peptic strictures.

Barrett's Esophagus: A serious complication of chronic GERD is Barrett's esophagus. In Barrett’s esophagus, the lining of the esophagus changes to resemble the intestine due to chronic acid exposure. Barrett’s esophagus is a recognized risk factor for cancer of the esophagus and needs long-term follow up.

Esophageal Cancer: GERD is the biggest risk factor for the most common type of esophageal cancer in the US (adenocarcinoma). In patients with chronic heartburn, an endoscopy will often be recommended to identify any suspicious or pre-malignant lesions, such as Barrett's esophagus. So, do not ignore your heartburn. If you are having heartburn two or more times a week, it is time to see your physician.

Increasingly, we are becoming aware that the irritation and damage to the esophagus from continual presence of acid can prompt an entire array of symptoms other than simple heartburn. Experts recognize that often the role of acid reflux has been overlooked as a potential factor in the diagnosis and treatment of patients with chronic cough, hoarseness and asthma-like symptoms. In some instances, patients have never reported heartburn, and in others the potential causal link between reflux and the onset of these so-called "extra-esophageal manifestations" has not been fully recognized. Physicians are increasingly becoming aware that it is good clinical practice to evaluate the possible presence of reflux in patients with chronic cough and asthma-like symptoms, as well as the importance that acid suppression and treating underlying reflux can have in potentially improving the symptoms in these patients.

• Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like heartburn and acid regurgitation. If your doctor says your chest pain is not coming from the heart, don't forget the esophagus. On the other hand, if you have chest pain, you should not assume it is your esophagus until you have been evaluated for a potential heart cause by your physician.
• Asthma: Acid reflux may aggravate asthma. Recent studies suggest that the majority of asthmatics have acid reflux. Clues that GERD may be worsening your asthma include: 1) asthma that appears for the first time during adulthood; 2) asthma that gets worse after meals, lying down or exercise; and 3) asthma that is mainly at night. Treatment of acid reflux may cure asthma in some patients and decrease the need for asthmatic medications in others.
• Ear, Nose and Throat Problems: Acid reflux may be a cause of chronic cough, sore throat, laryngitis with hoarseness, frequent throat clearing, or growths on the vocal cords. If these problems do not get better with standard treatments, think about GERD.

• Peptic Stricture: This results from chronic acid injury and scarring of the lower esophagus. Patients complain of food sticking in the lower esophagus. Heartburn symptoms may actually lessen as the esophageal opening narrows down preventing acid reflux. Stretching of the esophagus and proton pump inhibitor medication are needed to control and prevent peptic strictures.
• Barrett's Esophagus: A serious complication of chronic GERD is Barrett's esophagus. Here the lining of the esophagus changes to resemble the intestine. Patients may complain of less heartburn with Barrett's esophagus — that's the good news. Unfortunately, this is a pre-cancerous condition: patients with Barrett's esophagus have approximately a 30-fold increased risk of developing esophageal cancer. These patients should be followed by endoscopy by a trained gastroenterologist familiar with this disease.
• Esophageal Cancer: Recent scientific reports have confirmed that if GERD is left untreated for many years, it could lead to this most serious complication — Barrett's esophagus and esophageal cancer. Frequent heartburn symptoms with a duration of several years cannot simply be dismissed — there can be severe consequences of delaying diagnosis and treatment. This increased risk of chronic, longstanding GERD sufferers to develop cancer demonstrates the true severity of heartburn. In patients with chronic heartburn, an endoscopy will often be recommended to visually monitor the condition of the lining of the esophagus and identify or confirm the absence of any suspicious or pre-malignant lesions, such as Barrett's esophagus. So, do not ignore your heartburn. If you are having heartburn two or more times a week, it is time to see your physician and in all likelihood a gastrointestinal specialist. In most cases an endoscopy should be performed to evaluate the severity of GERD and identify the possible presence of the pre-malignant condition — Barrett's esophagus. The preventative strategy is to treat GERD. If it goes untreated and cancer does develop, the survival rate for esophageal cancer, at this time, is dismal.

Study links duration of heartburn to severity of esophageal disease

Esophageal disease may be perceived in many forms, with heartburn being the most common. The severity of heartburn is measured by how long a given episode lasts, how often symptoms occur, and/or their intensity. Since the esophageal lining is sensitive to stomach contents, persistent and prolonged exposure to these contents may cause changes such as inflammation, ulcers, bleeding and scarring with obstruction. A pre-cancerous condition called Barrett's esophagus may also occur. Barrett's esophagus causes severe damage to the lining of the esophagus when the body attempts to protect the esophagus from acid by replacing its normal lining with cells that are similar to the intestinal lining.

Research was conducted to determine whether the duration of heartburn symptoms increases the risk of having esophageal complications. The study found that inflammation in the esophagus not only increased with the duration of reflux symptoms, but that Barrett's esophagus likewise was more frequently diagnosed in these patients. Those patients with reflux symptoms and a history of inflammation in the past were more likely to have Barrett's esophagus than those without a history of esophageal inflammation.

Study links chronic heartburn to esophageal cancer

Persistent symptoms of heartburn and reflux should not be ignored. By seeing your doctor early, the physical cause of GERD can be treated and more serious problems avoided.

• Heartburn is a common, but not trivial condition.
  In fact, if left untreated, longstanding, severe and chronic heartburn has been linked with esophageal cancer. Don't ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution.
• If you suffer infrequent heartburn, antacids, or H2 blockers (now available without a prescription) or proton pump inhibitors (pending release at reduced strength over-the-counter dosages) may provide the relief you need.
• If you are experiencing heartburn two or more times a week, you may have acid reflux disease, also known as GERD, which, if left untreated, is potentially serious.
• If you are self-medicating for heartburn two or more times a week, or if you still have symptoms on your over-the-counter or prescription medication, you need to see a doctor and perhaps be referred to a gastroenterologist.
• GERD has a physical cause that's not your fault and can only be treated by a physician.
• If left untreated, longstanding, severe and chronic heartburn/GERD has been linked with esophageal cancer. Don't ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution.
• GERD has a significant role in asthma, chronic cough and ear, nose and throat problems — all referred to as extra-esophageal manifestations (EEM) although this connection may often go unrecognized. GERD should be actively considered in physician evaluations of these conditions, or it could go undetected.
• With effective treatment, using the range of prescription medications and other treatments available today, you can become symptom free, avoid potential complications and restore the quality of life you deserve.

Measure Yourself on the Richter Scale/Acid Test

How significant is your heartburn? What are the chances that it is something more serious? If you need a yardstick, here's a simple self-test developed by a panel of experts from the American College of Gastroenterology.

Remember, if you have heartburn two or more times a week, or still have symptoms on your over-the-counter or prescription medicines, see your doctor.

Take this "Richter Scale/Acid Test" to see if you're a GERD sufferer and are taking the right steps to treat it.

1. Do you frequently have one or more of the following:
   1. an uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach?
   2. a burning sensation in the back of your throat?
   3. a bitter acid taste in your mouth?
2. Do you often experience these problems after meals?
3. Do you experience heartburn or acid indigestion two or more times per week?
4. Do you find that antacids only provide temporary relief from your symptoms?
5. Are you taking prescription medication to treat heartburn, but still having symptoms?

If you said yes to two or more of the above, you may have GERD. To know for sure, see your doctor or a gastrointestinal specialist. They can help you live pain free.

• National Institute of Diabetes, Digestive and Kidney Diseases

• Heartburn: A Global Perspective Infographic