A few people that I know have asked me what I knew about acid reflux. I told them that I all I knew was that the valve at the end of the esophagus does not close completely and acid from the stomach is able to travel back up the esophagus and into the mouth. I was unsure what caused it and how to prevent or cure it. So that was the motivation for this blog.
I am sure many of you have had acid reflux at some point in your life. Maybe after eating a heavy meal or when you lie down after eating. Occasional acid reflux is completely normal in infants, children and adults (1). It is not a problem unless you have gastro esophageal reflux disease (GERD). People with GERD develop symptoms as a result of this disease. The main concern with GERD is developing cancer of the esophagus.
What is GERD (Gastro Esophageal Reflux Disease)
The esophagus is a 10 inch long tube that runs from the mouth into the stomach. There are muscles in the esophagus which expand and contract to push food down and into the stomach. Where the esophagus meets the stomach there is a circular muscle called the lower esophageal sphincter (LES). When food is swallowed the LES relaxes and lets food pass into the stomach. Once the food reaches the stomach the LES contracts to prevent food from going back up into the esophagus. Normally the LES functions properly and little if any food or acid go back into the esophagus.
GERD is a disease in which the LES does not properly close. Why does the LES fail to remain closed? There are a few possible reasons. The LES may become weak over time. Having a distended (swollen abdomen) stomach is another reason for failure of the LES to close. When the LES remains slightly open acid from the stomach and digested food can move back up. GERD can be defined as “symptoms of mucosal damage produced by the abnormal reflux of gastric contents into the esophagus” (2).
Acid produced in the stomach
Hydrochloric acid is produced in the stomach to help digest food. Hydrochloric acid is the main acid responsible for damage to the esophagus. The reason this acid does not damage the stomach is because we have a mucosal lining in our stomach that prevents the acid from reaching the stomach wall. When we develop a breach in the mucosal lining of the stomach, called a peptic ulcer, acid is able to reach and damage the lining of the stomach.
Symptoms of GERD
Common symptoms of GERD include heart burn, vomiting and pain with swallowing. People that experience heart burn at least two to three times per week may have GERD (1). Symptoms of heart burn include a burning sensation in the center of the chest and/or throat and an acid taste in the throat (how someone would know what acid tastes like I do not know). Other less common symptoms include: persistent sore throat, chronic cough, difficulty or painful swallowing, regurgitation of food, sense of a lump in the throat or upper abdominal pain.
When does acid reflux occur?
Heart burn and food regurgitation will often occur after a large meal or a meal containing a lot of dietary fat (2). These symptoms may be worse when bending over and usually are relieved with antacids. Episodes of gastric reflux typically only last 3-5 minutes but at the end of the day this translates to the mucosa in the esophagus spending one to two hours in contact with the acid reflux (3).
How GERD is diagnosed
If someone has symptoms of GERD but no complications the doctor will likely prescribe medication and advise lifestyle changes. In some cases an endoscopy will be performed where a doctor uses a tube to examine the esophagus and takes a sample of tissue to asses for damage. Another method is having a person swallow a tube and measuring the muscle contractions of the esophagus to see if it is functioning properly.
If an endoscopy finds Barrett’s Esophagus (definition is below) or esophagitis (inflammation of esophagus) the person most certainly has GERD (3). But even if an endoscopy comes back normal this does not rule out the possibility of having GERD. To complicate matters further, a majority of symptomatic patients will have a normal endoscopy (3). Just because someone has esophagitis does not always mean that the person has more severe GERD than someone that has a normal endoscopy which can make treating GERD complicated (3).
Because many people with GERD do not have esophigitis and a normal endoscopy does not mean for certain that someone does not have GERD doctors may prescribe ambulatory monitoring of the esophagus (3). Patients with less extreme acid reflux develop the same symptoms as patients with severe acid reflux and thus require the same treatments. While ambulatory pH testing is not perfect it does offer the best option to monitor the actual amount of reflux in a given patient. Two newer and less invasive methods for measuring reflux include a technology that allows monitoring of both acid and the volume (nonacid) reflux while the other is a tubeless method of acid monitoring (3).
Most people with GERD will never experience major complications. However, a lifetime of having acid go back up the esophagus can cause major problems.
Ulcers (holes in the mucosal lining) can develop in the esophagus from the continuous presence of stomach acid which burns holes in the esophagus. Although not visible to us bleeding can result from these ulcers. Doctors can detect this blood in stool samples.
Stricture is when the acid damages the esophagus causing it to scar and narrow. I don’t think I need to tell you what problems a narrowed esophagus can cause (choking!). Scarring results from the constant burning and healing of the esophagus tissue. Scarring causes thickening of tissue and narrowing of the esophagus.
Barret’s Esophagus results when constantly damaged tissue in the esophagus transforms from squamous cells into intestinal cells. These intestinal cells have a higher chance of developing into cancer cells and frequent endoscopies are necessary to check for cancer cells. Developing Barrett’s Esophagus is the most significant concern for those with GERD.
Espohagitis is inflammation that may damage the lining of the esophagus. This condition can cause painful and difficult swallowing along with chest pain. If left untreated this can lead to stricture and difficulty swallowing. Symptoms include: difficulty swallowing, food getting stuck in the esophagus, painful swallowing, chest pain behind the breast bone and heart burn. If you have any of these symptoms for more than a few days see your doctor.
GERD general treatments
There are a few options for treatment ranging from simple lifestyle modifications to surgery. If there is no damage to your esophagus the doctor will likely start with diet or lifestyle changes. If there is significant damage to your esophagus more serious treatment will be needed. If patients thought to have GERD respond well to therapy specific to GERD it can be assumed that the patients indeed have GERD. When GERD is not relieved when making appropriate changes there is a chance the person does not have GERD but even still this does not completely rule out the possibility (3).
Unfortunately one of the easier methods of treatments, lifestyle modification, does not offer acid reflux relief for the majority of patients (3). Some lifestyle treatments that have been shown to offer some relief although not rigorously studied include elevating the head of the bed (this does not mean using many pillows- this may actually worsen acid reflux), decreasing dietary fat intake, stopping smoking, and avoiding laying down within three hours after consuming a meal
GERD specific treatments
Antacids and antirefluxants – Both antacids and antirefluxants can be bought over the counter. I am sure most of you know common antacids like alka seltzer, Mylanta, Tums and Maalox. A common antirefluxant is alginic acid. Antacids contain base minerals like magnesium which counterbalance the acid in your stomach (bases neutralize acids- if you remember anything from high school chemistry it is likely this). Alginic acid is often used with antacids.
Alginic acid forms a layer on top (they soak up water and for a gel) of the stomach which prevents acid from leaving the stomach and entering the esophagus. It acts like a protective coating for the stomach. From what I can tell alginic acid can be ordered in supplement form from drug websites or a site like Amazon. I do not want to be viewed as promoting one website or brand over another so I will leave it up to you, but if you have any questions you can email me the product name and I will let you know what I think. I am fairly certain you can get prescriptions as well.
Both of these treatments are effective at treating milder cases of GERD. In a study they have been shown to be more effective than a placebo in relieving heart burn (3). An antacid/alginic acid combination is more effective than taking only an antacid. There are two long term trials which have shown relief in 20% of patients taking over the counter drugs (3).
H2RA- also known as H2 receptor antagonist. These drugs work by blocking the action of acid producing cells in the stomach thereby reducing total acid production in the stomach. These drugs have longer durations than antacids (6-10 hours versus 1-2 hours for antacids) and can be used before meals to reduce the chance of getting heart burn. Some examples are Pepcid, Zantac and Tagamet. All of these drugs are available over the counter (no prescription required). These medications are supposed to be used only 14 days straight and any use beyond this time requires a doctor visit as some of these patients may be at risk for Barrett’s Esophagus or other upper gastrointestinal problems (3). Higher doses may be more effective.
Protein pump inhibitors – (PPI’s) – this is the only acid suppressing option that not only helps the symptoms of GERD but actually promotes healing of the esophagus! The results of 33 randomized trials involving GERD found symptom relief in 60% of patients taking H2RA’s and 78% of patients taking PPI’s (3). Esophagitis was healed in 50% of patients taking H2RA’s and 78% of patients taking PPI’s (3). In addition to healing espohagitis better than H2RA’s, PPI’s also heal it quicker.
PPI’s are safe and have been used for more than a decade in the United States. Any harm from long term use of PPI’s is outweighed by the significant benefits it produces in those with GERD. A few patients have suffered vitamin B12 deficiency so if you plan on takings PPI’s long term makes sure to get your vitamin B12 levels checked in blood work. The five available PPI’s are: omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole. I am pretty sure these are all prescription drugs.
Surgery – surgery is an option for those with severe GERD. Surgery carries many inherent risks and is advised for younger patients with GERD. Its long term effectiveness is controversial as well. Surgery is best discussed with your doctor. One study found that even after surgery 62% of patients continued taking antireflux medications (5).
Endoscopic Therapy- Endoscopic therapy is a new treatment that controls GERD endoscopically (3). There are three different treatments which are all rather technical but they are an alternative treatment to both medication and therapy. Short term studies have proven the effectiveness of endoscopic therapy at reducing symptoms of GERD but long term results are not as well studied. Besides the issue of only having a few studies on this topic, most of the studies had few participants. Before this can be considered an effective long term therapy more studies need to be undertaken but preliminary studies look promising.
GERD is a lifelong disease
Unfortunately GERD is a chronic condition and when patients stopped taking PPI’s their acid reflux came back. Most patients require lifelong therapy. Because of this it is best to find out the least amount of medicine you need to take to control your GERD to reduce the side effects from the medications. H2RA’s do not suppress GERD long term nor do low doses of PPI’s. Because of this increased doses of PPI’s may be required for long term suppression of the disease. Even with control of GERD patients will experience relapses of acid reflux throughout their life. Rather a depressing diagnosis.
Most acid reflux events are not perceived by patient
Complicating things further, most episodes of acid reflux are not even perceived by the patient. One study found that less than 5% of the acid reflux events were perceived by the patient (4).
Progression of the disease
There is still much confusion about the natural progression of this disease. Oddly enough the few long term studies out there show that patients without mucosal damage of the esophagus do not usually develop damage the longer they have GERD. This goes against common sense and there must be more long term studies to clarify this issue. It seems that it is only possible to develop esophageal cancer if one has Barrett’s Esophagus first, so even having GERD but without Barrett’s Esophagus the chance of developing cancer is very low. Studies have shown that those with erosive esophagitis, no matter how severe, rarely progress to Barrett’s Esophagus, IF they lack Barrett’s epithelium underneath the inflammation (4).
Can we assume that those with normal mucosa of the esophagus have less severe GERD than those with esophageal damage? Surprisingly, the answer is likely no. Many patients without mucosal damage have chronic cough, asthma, hoarseness and other laryngeal symptoms that may reflect the complications of their underlying disease (4). Because of this, those with normal mucosa of the esophagus should be treated similar to those with mucosal damage of their esophagus.
While the blog has been very interesting to write I am left confused about the subject. It appears that there is a lot of uncertainty about treatment effectiveness, progression of the disease and the likelihood of getting cancer. There is uncertainty because there are so few long term studies of people with GERD. I was surprised that GERD is so hard to control and is a lifelong disease. It seems despite lifestyle modifications and diet adjustment those with GERD will continue to have symptoms.
I did not go over problem foods since very few people can relieve acid reflux by cutting out certain foods. Some foods may aggravate it but there are few studies showing which foods are worst. If you really have GERD cutting out certain foods will offer little to no relief.
The main danger of having GERD is developing cancer of the esophagus. If you suspect you have this disease it is best to talk with your doctor as soon as possible and have an endoscopy performed to check for damage to the lining of the esophagus. Antacids and antirefluxants can be effective but these options are best discussed with your doctor. In the meantime you can eat smaller meals, not lay down after meals and not consume too much fat at once. These may offer some relief but will not cure GERD.
This blog is not meant to scare those with GERD. Most people that have GERD will never develop Barrett’s Esophagus and thus will never develop Esophageal Cancer. This blog is to inform people about the disease and ways to treat it. I hope that over time there is better understanding of the disease and better long term treatment options.
1) Kahrilas, P. J. (1996). Gastroesophageal reflux disease. Jama, 276(12), 983-988.
2) DeVault, K. R., & Castell, D. O. (2005). Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The American journal of gastroenterology, 100(1), 190-200.
3) Orlando, L. A., & Orlando, R. C. (2004). Pathophysiology of GERD: esophageal epithelial defense. Practical Gastroenterology, 28(7), 14-27.
4) Fass, R., & Ofman, J. J. (2002). Gastroesophageal reflux disease—should we adopt a new conceptual framework&quest. The American journal of gastroenterology, 97(8), 1901-1909.
5) Spechler, S. J., Lee, E., Ahnen, D., Goyal, R. K., Hirano, I., Ramirez, F., … & Williford, W. (2001). Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial.Jama, 285(18), 2331-2338.