Heartburn, the commonest symptom of acid reflux affects one in four adults in the United Kingdom every month and one in ten every week. It is one of the commonest reasons for people visiting their GP and is most definitely an illness of our times. Fifty years ago everyone had stomach ulcers. Ulcers are found far less often these days at endoscopy, but heartburn has taken over and is now very common indeed.
In these pages, we explain the causes, symptoms and treatments for acid reflux. We also introduce you to a number of remedies which you can try yourself as well as cures which the doctor has available to help you. We will also tell you a little about surgery and the novel endoscopic techniques, which claim to cure reflux symptoms. We will show you why you should be careful before taking the surgical route. There is no doubt that surgery is appropriate for some people, but by no means for everyone. Many people get significant benefit if they are careful with their diet, whereas others need conventional, or sometimes, second line medication.
Curiously, most acid reflux attacks occur during the day, but some people are bothered particularly at night. These people are most at risk from chronic cough, a symptom which is often not recognised as being related to stomach problems as they often do not have heart burn or other more typical symptoms.
Please note that not all indigestion symptoms are related to acid at all. In one interesting study, older people with osteoporosis frequently complained of heartburn, even though they did not have acid reflux. This is something we see quite frequently in our practice. It is probably due to the nerves feeding the oesophagus being pinched due to the poor back posture (kyphosis) that these people have. It is therefore important to sort out the cause of heartburn so that the correct treatment can be offered.
The stomach normally produces acid to help destroy bacteria in the food we eat. So what is acid reflux? It is not, as many people think, the production of too much acid. Rather, it is the movement of stomach contents back up from the stomach into the oesophagus (gullet). It is now one of the commonest causes of indigestion.
This is the burning and sometimes painful sensation which people feel rising from the pit of the stomach up into the chest. This occurs as the acid rises up into the oesophagus.
The lining of the stomach always produces a small amount of acid but this increases dramatically as soon as we start eating food. When the stomach is full, it not only has food in it, but it turns into an acidic bag, which churns and breaks down the food into small pieces which the body can absorb. This environment helps to start the process of digestion.
If people eat reasonable amounts, the food is let out into the small bowel for further digestion a little at a time. If people eat too much, however, the full stomach is under pressure. It needs to relieve that pressure, particularly if the owner of the stomach has a big belly, or is wearing tight clothes. The stomach has an escape valve, like an overflow valve in a hot water system. This valve or sphincter sits at the top of the stomach and allows gas and liquid to escape upwards into the oesophagus.
It often surprises people that these transient lower oesophageal sphincter relaxations (TLOSRs) occur particularly after eating. It is, however true, that most episodes of acid reflux happen within two hours of eating. They are more common after eating particular foods and the larger the meal, the more likely TSLORs will occur and that the person will suffer acid reflux symptoms.
A number of factors will influence how likely you are to suffer TLOSRs. If you have a hiatus hernia, the lower oesophageal sphincter will work less well. Coffee relaxes the sphincter rather too much and is the cause of a lot of misery. New drugs aim to decrease the frequency of TLOSRs.
Eating large meals increases the pressure in the stomach and the likelihood of transient lower oesophageal sphincter relaxations (TLOSRs).
The following foods make reflux worse by relaxing the lower oesophageal sphincter:
These foods are acidic and cause direct irritation of the oesophagus:
People do not realise that some of the medicines they take can be potent acid reflux causes. A slight change to medicines taken for other reasons, can make a big difference to the symptoms they suffer.
Once again, medicines can be divided into those which directly irritate the oesophagus and those which relax the lower oesophageal sphincter and make acid reflux more likely to occur.
Medicines which cause reflux by relaxing the lower oesophageal sphincter
Muscle relaxants such as diazepam, theophylline, nitrates, and calcium channel blockers egnifedipine or amlodipine.
Other drugs can also cause reflux. Please discuss with your doctor if you think a drug is causing or aggravating the symptoms.
Acid reflux causes include overweight. This group of peope are at particular risk. It is particularly marked in people with central obesity (beer belly!). The reason is simple. The fat in the abdomen places pressure on the stomach and this forces the acid contents back up into the oesophagus, particularly after a large meal.
If you lie down or bend forward a lot during the day, this will encourage reflux. If you sit hunched (perhaps in front of your computer for long periods?!) or if you wear a tight belt, this may put extra pressure on the stomach which may make reflux worse.
We have already said that most reflux occurs within two hours of meals. Most reflux episodes resolve because gravity pulls the acid back into the stomach. But, if a person lies down too soon after eating, gravity cannot act. So, going to bed within two hours after eating is an important cause of heartburn or reflux in the night.
An acid reflux attack can be really unpleasant, particularly if you have never had one before. At its worst, it resembles a heart attack, with severe central chest pain which goes up into the shoulder. If this happens, you need to go to hospital to be checked. If it is less severe, it can still cause bad heartburn, chest pain, or nausea and even vomiting.
Chest pain due to acid reflux attacks can be almost impossible to distinguish from a heart attack and if it is severe, it needs to be treated very seriously. Nevertheless, there are a few tell-tale signs that the problem is due to digestion.
You may need an ECG or blood tests to be able to distinguish chest pain due to reflux (also called ‘atypical chest pain’) from a heart attack. If this happens to you, please call your doctor urgently for advice.
This is the most typical symptom of an acid reflux attack. Heartburn is a burning sensation which starts in the pit of the stomach, just below the bottom of the breastbone, and rises through the chest. It is typically brought on by eating, particularly large or fatty meals. It may also be caused by exercise or bending forward.
Waterbrash means bringing a bitter or acidic tasting fluid into the back of the mouth. Once again, this particularly happens after eating, exercising or bending forward. If it happens at night, the acidic fluid can go into the lungs. This causes a terrible feeling of choking which can last for a minute or two before subsiding. This choking feeling is never fatal but it is very unpleasant. Fortunately, there are good treatments to prevent this occurring. Indeed, this symptom is the one which tends to respond best to antireflux surgery.
Dysphagia means difficulty swallowing. There are many causes but if solid foods get stuck before reaching the stomach, this can be due to acid reflux. It can, however, be a sign of oesophageal cancer and so urgent referral to a specialist is recommended if this occurs.
An on-going intermittent cough can be due to acid reflux and can actually be the only sign a person has the condition. It is usually easily treated and responds well to medicines
One of the really strange effects of an acid reflux attack is that it can cause a person to become hoarse. If the attack occurs in the middle of the night, the person may not even realise it has happened. Instead, they wake up with a hoarse voice which can last for a few days. If attacks occur frequently, a person can have a hoarse voice which never gets better. This needs proper investigation and specialised treatment to cure because acid reflux attacks which present in this way are very difficult to detect.
The commonest test needed to investigate suspected acid reflux is endoscopy. This looks for inflammation (oesophagitis) and other complications but it does not actually measure the amount of acid reflux itself. A better test for this, which may be done in addition, is 24 hour pH studies. This test is not the favourite test for many people and we are delighted that we can offer the BRAVO ambulatory pH study which can be done at the same time as the endoscopy. This allows for immediate assessment of the severity of acid reflux during the endoscopy without the need for further tests. Please look here for more details.
Many people will take acid reflux treatment without being formally diagnosed by endoscopy, 24 pH studies or BRAVO pH tests. This may work in the short term, but for most people, particularly if the symptoms last for a significant time or don’t completely recover with medicine, it is important to have formal testing to ensure that the diagnosis is correct.
Acid reflux treatment really contains three essential elements. These are:
Some people are able to manage their heartburn or other reflux symptoms by dietary changes alone. Although many people do not realise it, most episodes of reflux occur in the two hours after eating. The more you eat, the more likely you are to suffer. What is more, if you lie down soon after eating, acid which has gone up into your oesophagus is less likely to clear because gravity is not working for you!
If you suffer, try avoiding large meals or eating late at night. Many people find that avoiding coffee makes a very big difference and don’t forget that chewing sugar free chewing gum for a quarter of an hour just after a meal can help settle the stomach.
For about a quarter of all sufferers, particularly younger people, once the symptoms are under control, they can return to normal and don’t suffer any more.
In many people, however, reflux symptoms do not respond to diet alone. These people need medicines to make them feel better. Medicines can be thought of as those which relieve symptoms and those which prevent reflux in the first place. Many of the modern medicines are highly effective and have almost no side effects.
For the very few people who do not respond to medicine, or who do not want to take drugs long term, anti-reflux surgery is an option. No one wants to opt directly for surgery, and with the array of other treatments now available, this option should really be saved for last.
Acid reflux treatment has improved very significantly over the last 20 years. It should now be possible to help the vast majority of sufferers to return to normal life, and most people should be able to eat quite normally with minimal symptoms.
Acid reflux is unpleasant. You get that awful feeling of acid in your chest, or all the way back into your throat. But you don’t want to take time off work to see a doctor. Are there any things that you can do yourself?
Well, you have already tried over the counter antacids. Are there any other things you can try at home?
Many people have discovered the value of sugar free chewing gum. The idea is simple. Straight after eating is the time that most acid reflux occurs. If you chew gum, you make saliva. This is a natural way of neutralising acid. As you swallow your saliva, you stop the acid burning your oesophagus because you push the saliva back down into the stomach.
How about a nice simple idea? If you get reflux, drink a glass of milk. This will push the acid back down into the stomach where it belongs. It will also buffer and neutralise it at the same time. It is a good trick if you wake in the middle of the night and have nothing else to hand. It certainly works quickly and is generally better than a glass of water.
You are better off with fat-free skimmed milk. This is because fat slows down stomach emptying. Fat free milk does not. After eating, it is better for the stomach not to be too full. The fuller it is, the more the acid reflux will occur.
Some people still like to take bicarbonate of soda (sodium bicarbonate). This remedy has been around for many years and works to simply buffer the acid in your stomach. It fizzes and helps people to burp. Some people claim that burping makes them feel better.
There is an interesting piece of research on using Melatonin. Melatonin is a naturally produced hormone which helps people sleep. You can buy it as a food supplement.
Curiously, some people claim that it helps relieve heartburn. There is really very little research on this, but we have certainly met people who are absolutely certain that it has helped them. If you want to try melatonin, be aware that in some people has side effects and it might interact with other medicines you are already taking. (always read the label before taking any medicine or food supplement and discuss it with your doctor).
There are other home remedies available. Please go to our Facebook page and suggest the ones that work best for you.
Shall I describe an acid reflux diet? I don’t mean a diet to prevent reflux. No! Let me tell you about a perfect lunch. But watch out, it just might make you suffer.
You meet a long lost friend at a café. It is mid morning. You order a cappuccino. You sit and chat and before you know it, lunchtime arrives. You are feeling very healthy, so you have orange juice instead of a starter. Next up is a pizza neapolitana and over a glass of red wine, you chat. The chocolate mousse looks so appetising. You just can’t resist a little indulgence. The sun is shining and just before you head back to the office, you take a drink of sparkling water to keep you well hydrated.
Boy, are you in for a miserable afternoon. A large meal, with coffee, chocolate, orange juice, alcohol and a fizzy drink. Add to that the fat from the cheese. Now that is a meal just waiting to give you a serious bout of indigestion, or worse still, chest pain!
Next time you go out, you are a little wiser. You decide to have peppermint tea instead of coffee. You avoid the fatty food and go for a salad nicoise. You have still water instead of sparkling. For dessert, you choose the fruit salad. The fruits are fresh summer goodies like melon, grapes and strawberries.
You now know that any fruit might upset you, but because you have cut back on the really nasty things like coffee, chocolate and fizzy drinks, you are probably going to be able to indulge a little. You have a piece of meringue with those strawberries and low fat yoghurt and feel very pleased with yourself.
You also have an easy afternoon in the office and you were still able to enjoy your rendezvous with that long lost friend. No indigestion. No fatty food. A really good anti acid reflux diet!
We have some recipes for great tasting food that you can eat without aggravating your symptoms:
Additionally, see the table below for good foods to eat and food to avoid to manage your acid reflux.
Need to see a doctor? Are you worried that you need an endoscopy to assess the cause of your heartburn? Choose the specialist who is right for you here or maybe you need a specialist dietitian who can advise you on what to eat and what foods to avoid? Just phone our office on 020 7183 7965 and we will be delighted to help you!
|Foods to avoid||Good Foods to eat|
|Coffee||Weak herbal teas (too strong and they can cause your stomach to make acid)|
|Fizzy drinks||Still water|
|Spicy foods||Pretzels, rice cakes, bread, corn thins|
|Citrus||Pears, bananas, apples. Some soft summer fruits such as ripe melon|
|Tomatoes||Baked potato, broccoli, cabbage, carrots, peas and green beans|
|Fatty foods||Low fat foods such as white fish, lean meat or poultry, cottage cheese and low fat yoghurt|
|Large meals||Smaller meals, perhaps eat more often|
|Do not eat late at night||Leave at least 2-3 hours between eating and going to bed|
|Alcohol||Non alcoholic drinks|