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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.
What is Acid Reflux
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.
What is Heartburn?
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.
Causes of Acid Reflux
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:
- Coffee (even decaffeinated)
- Fizzy drinks
These foods are acidic and cause direct irritation of the oesophagus:
- Citrus fruit such as oranges, lemons and grapefruit
- Orange juice
- Spicy foods such as curry
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.
Direct irritation of the oesophagus:
- Anti-inflammatory painkillers (such as ibuprofen or aspirin)
Relaxing the lower oesophageal sphincter
- Muscle relaxants and calcium channel blockers.
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.
Acid Reflux Symptoms
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. 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:
- have you just eaten a large or fatty meal? (more likely reflux)
- are you young and fit and can you usually do vigorous exercise? (more likely reflux)
- have you suffered with indigestion in the past? (more likely reflux)
- did the pain come on after exercise? (more likely heart)
- are you also breathless? (more likely heart)
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.
Heartburn. 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 and Choking. 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. 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.
Cough. 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
Hoarse Voice. 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 most common 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.