Acid Reflux Disease

Gastroesophageal reflux disease, or acid reflux disease, occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus.

The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The esophagus carries food from the mouth to the stomach.

When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has acid reflux disease. Heartburn that occurs more than twice a week may be considered acid reflux disease, and it can eventually lead to more serious health problems.

Anyone, including infants, children, and pregnant women, can have acid reflux disease.

What are the symptoms of acid reflux disease?
The main symptoms are persistent heartburn and acid regurgitation. Some people have acid reflux disease without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. acid reflux disease can also cause a dry cough and bad breath.

acid reflux disease in Children
Studies* show that acid reflux disease is common and may be overlooked in infants and children. It can cause repeated vomiting, coughing, and other respiratory problems. Children's immature digestive systems are usually to blame, and most infants grow out of acid reflux disease by the time they are 1 year old. Still, you should talk to your child's doctor if the problem occurs regularly and causes discomfort. Your doctor may recommend simple strategies for avoiding reflux, like burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. If your child is older, the doctor may recommend avoiding

sodas that contain caffeine
chocolate and peppermint
spicy foods like pizza
acidic foods like oranges and tomatoes
fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. The doctor may recommend that the child sleep with head raised. If these changes do not work, the doctor may prescribe medicine for your child. In rare cases, a child may need surgery.

*Jung AD. Gastroesophageal reflux in infants and children. American Family Physician. 2001;64(11):1853-1860.

What causes acid reflux disease?
No one knows why people get acid reflux disease. A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus. When a hiatal hernia is present, it is easier for the acid to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.

Other factors that may contribute to acid reflux disease include

alcohol use
overweight
pregnancy
smoking
Also, certain foods can be associated with reflux events, including

citrus fruits
chocolate
drinks with caffeine
fatty and fried foods
garlic and onions
mint flavorings
spicy foods
tomato-based foods, like spaghetti sauce, chili, and pizza

How is acid reflux disease treated?
If you have had heartburn or any of the other symptoms for a while, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your acid reflux disease is, treatment may involve one or more of the following lifestyle changes and medications or surgery.

Lifestyle Changes
If you smoke, stop.

Do not drink alcohol.

Lose weight if needed.

Eat small meals.

Wear loose-fitting clothes.

Avoid lying down for 3 hours after a meal.

Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts--just using extra pillows will not help.
Medications

Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach.

Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild acid reflux disease symptoms. Many brands on the market use different combinations of three basic salts--magnesium, calcium, and aluminum--with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.

Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.

Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the esophagus.

H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have acid reflux disease symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.

Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has acid reflux disease.

Another group of drugs, prokinetics, helps strengthen the sphincter and makes the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.

Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for acid reflux disease.

What if symptoms persist?
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.

A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus--called stricture--ulcers, hiatal hernia, and other problems will.

Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm acid reflux disease.

The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found.

In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with acid reflux disease symptoms but no esophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.

Surgery
Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for acid reflux disease. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.

This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.

Implant
Recently the FDA approved an implant that may help people with acid reflux disease who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the esophagus. It is injected during endoscopy. The implant is approved for people who have acid reflux disease and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.

What are the long-term complications of acid reflux disease?
Sometimes acid reflux disease can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer.

Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by acid reflux disease.

For information about Barrett's esophagus, please see the Barrett's Esophagus fact sheet from the National Institute of Diabetes and Digestive and Kidney Diseases.

Points to Remember
Heartburn, also called acid indigestion, is the most common symptom of acid reflux disease. Anyone experiencing heartburn twice a week or more may have acid reflux disease.

You can have acid reflux disease without having heartburn. Your symptoms could be excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the mouth, or pain in the chest.

In infants and children, acid reflux disease may cause repeated vomiting, coughing, and other respiratory problems. Most babies grow out of acid reflux disease by their first birthday.

If you have been using antacids for more than 2 weeks, it is time to see a doctor. Most doctors can treat acid reflux disease. Or you may want to visit an internist--a doctor who specializes in internal medicine--or a gastroenterologist--a doctor who treats diseases of the stomach and intestines.

Doctors usually recommend lifestyle and dietary changes to relieve heartburn. Many people with acid reflux disease also need medication. Surgery may be an option.

Hope Through Research
No one knows why some people who have heartburn develop acid reflux disease. Several factors may be involved, and research is under way on many levels. Risk factors--what makes some people get acid reflux disease but not others--are being explored, as is acid reflux disease's role in other conditions such as asthma and bronchitis.

The role of hiatal hernia in acid reflux disease continues to be debated and explored. It is a complex topic because some people have a hiatal hernia without having reflux, while others have reflux without having a hernia.

Much research is needed into the role of the bacterium Helicobacter pylori. Our ability to eliminate H. pylori has been responsible for reduced rates of peptic ulcer disease and some gastric cancers. At the same time, acid reflux disease, Barrett's esophagus, and cancers of the esophagus have increased. Researchers wonder whether having H. pylori helps prevent acid reflux disease and other diseases. Future treatment will be greatly affected by the results of this research.