Acid Reflux

What is acid reflux?

Acid reflux, also called Gastroesophageal Reflux Disease or GORD or GERD, is a common problem. It is caused by the backflow of liquid from your stomach into your oesophagus (gullet). The stomach makes acid for digestion, but the lining of the lining of the oesophagus is not built to tolerate acid. Some reflux occurs normally in most people. The reflux becomes a problem – a disease – when it causes troublesome symptoms or complications.

What causes acid reflux?

The lower end of your oesophagus (gullet) has a natural barrier or valve (called the lower oesophageal sphincter) to prevent the backflow of acid from the stomach. Excessive stomach acid can enter your oesophagus if the valve does not work properly. One condition that can cause weakness of the valve is a hiatus hernia. This is a condition in which your stomach moves upwards from the abdomen (tummy) into the chest. But, not all patients with acid reflux have a hiatus hernia. There may not be any obvious cause for malfunction of the valve.

What are the symptoms of acid reflux?

Heartburn is the most common symptom of acid reflux. You feel a painful burning sensation that starts at the top of your abdomen (tummy). The burning pain radiates up behind your breastbone, towards your neck. Also, you can have backflow of partially digested food or liquid from your stomach into your mouth. This is called regurgitation. Some people with acid reflux disease will have both heartburn and regurgitation. Others may have only heartburn or only regurgitation. Also, you may get a sensation of food sticking behind your breastbone or pain whilst swallowing. Some people get chest pain, chronic cough, hoarseness of voice and asthma. These are called atypical symptoms of reflux.

What are the complications of acid reflux?

Acid reflux can cause inflammation and erosions in the inner lining of your oesophagus (gullet). This condition is called erosive oesophagitis. Because of the inflammation, your oesophagus can become narrow and you may get difficulty to swallow. This is called stricture or stenosis of the oesophagus. Long standing reflux can cause a condition called Barrett’s oesophagus. In Barrett’s oesophagus, the normal cells in the lining of the oesophagus are replaced by abnormal cells called intestinal metaplasia. These abnormal cells are in themselves benign, but have increased risk of turning into cancer. Barrett’s oesophagus is a pre-malignant condition of the oesophagus.

What is the medical treatment for acid reflux?

Acid reflux should be suspected if you are getting heartburn. The treatment of heartburn starts with simple lifestyle changes. Healthy eating, weight loss, stopping smoking and not eating before bedtime can be very helpful. Your doctor may prescribe some medicines called Proton Pump Inhibitors or PPIs, like omeprazole, lansoprazole, esomeprazole or pantoprazole. These drugs reduce the secretion of acid from the lining of your stomach. PPI drugs can be given in different doses, according to the severity of your problem. It is very important to take the PPI on an empty stomach. If you take a PPI in the morning, it should be 15-30 minutes before breakfast. If you take it in the evening, it should be 15-30 minutes before your evening meal and not just before going to bed. Antacid medications, like Gaviscon®, can be helpful along with PPIs. You may be prescribed another acid-reducing drug, called ranitidine, if your heartburn is not controlled by a PPI. Ranitidine should be taken just before going to bed. It is really important to take the medicines at the right times to get the best effect.

Do I need to have any tests if I am getting heartburn?

Not everyone with heartburn needs to have tests for acid reflux. No tests may be needed if your heartburn is well controlled with lifestyle changes and PPI medicines. But, an endoscopy should be done if you have ‘alarm’ symptoms or high-risk factors or if the medicines do not control your symptoms.

What are the tests for acid reflux?

Tests are done for two reasons. First, to make sure that your heartburn and other symptoms are because of acid reflux and not some other problem. And second, to find out the severity of the reflux. There are three types of tests for acid reflux. Depending on your individual condition, you may need to have only one or more tests.

Usually, the first test is an endoscopy. One purpose of the endoscopy is to see if acid reflux has caused erosions (breaks in the lining) in your oesophagus (gullet). About 1 in 3 patients with acid reflux disease have erosions. But, the absence of erosions does not rule out acid reflux. It simply means that the acid has not obviously damaged your oesophagus. Also, endoscopy looks for other complications of acid reflux, like stenosis and Barrett’s oesophagus. Endoscopy can detect a hiatus hernia that may be a cause for acid reflux. The entire lining of the stomach and oesophagus can be inspected to rule out any serious problem, like cancer.

A barium swallow x-ray may be needed. This x-ray can give important information about the size of a hiatus hernia.

Oesophageal Function Tests  are needed if the diagnosis of acid reflux is not clear or if an operation for acid reflux is being considered.

WHEN SHOULD I THINK ABOUT AN OPERATION FOR ACID REFLUX?

An operation for acid reflux is called anti-reflux surgery. You should think about anti-reflux surgery if you have heartburn or other symptoms of reflux AND you have 1) PPI dependence OR 2) Refractory symptoms.

You are dependent on PPI medicines like omeprazole or lansoprazole. Your symptoms are well controlled for as long as you take these medicines regularly. But, you get troublesome symptoms if you stop taking the drugs or occasionally miss a dose. You may find it inconvenient to take the medicines regularly. Also, you might be worried about the side-effects of long-term PPI treatment. PPI treatment is generally safe but some concerns have been raised. Studies have shown that prolonged PPI treatment may increase the risks for atrophic gastritis, changes in the bacterial flora of the gut and increased risk for bowel infection (e.g. Clostridium difficile diarrhea), fractures, and deficiencies of iron, vitamin B12 and magnesium.

You are taking PPI medicines but you continue to suffer with heartburn or other symptoms or reflux. Your symptoms may not be responding to treatment for a number of reasons. Your body may have naturally poor response to PPI drugs or your reflux may be severe. But, alternative conditions need to be considered. You can get heartburn without having true acid reflux. This condition is called Functional Heartburn. Also, reflux-like symptoms can occur with other conditions, like achalasia and gastroparesis. It is critical to make the correct diagnosis so that you can get the correct treatment.

DOES SURGERY HELP EVERYONE WITH SYMPTOMS OF ACID REFLUX?

The decision about anti-reflux surgery has to be made very carefully. It is necessary to make sure that your symptoms are truly because of acid reflux. Oesophageal function tests are important guides for making a decision about anti-reflux surgery. These tests have two components: manometry and 24-hour pH study.

The manometry test is important to make sure that the muscles of the oesophagus are working. Rarely, there may not be any movement in the muscles. This condition is called amotility or severe dysmotility of the oesophagus. It is found in disorders like achalasia. Anti-reflux surgery is very unlikely to help in these conditions.

The 24-hour pH test gives detailed information about the backflow of acid from your stomach into your oesophagus. It checks the time for which your oesophagus is exposed to acid. Also, it checks whether your symptoms are linked to acid exposure. There are three possible scenarios:

You have abnormally long acid reflux and your symptoms are linked to the reflux. In this situation, you are likely to have good response to anti-reflux surgery.

You have acid reflux within the normal range. Remember, we all have some acid reflux during 24 hours. But, your symptoms are linked with the episodes of acid reflux. You may have a condition called Hypersensitive Oesophagus. Anti-reflux surgery may help, but careful discussion and decision-making is essential.

You have acid reflux within the normal range. There is no linkage between your symptoms and the episodes of acid reflux. It is likely that you have a condition called Functional Heartburn. Anti-reflux surgery is very unlikely to be of help.

WHAT IS ANTI-REFLUX SURGERY?

There are three different operations for the treatment of acid reflux:

1) Nissen fundoplication. 2) LINX. 3) Roux-en-Y Gastric Bypass.

All the operations are done by keyhole surgery. The choice of operation depends on your individual circumstances. Nissen fundoplication is the commonly performed anti-reflux operation. But, it does have some side-effects and limitations. LINX is a good alternative to Nissen fundoplication for some people. The gastric bypass is commonly used as a weight loss operation. For people who are severely obese and have acid reflux, the gastric bypass is the recommended for the treatment of acid reflux.

Print this page | Last updated: 04/09/2016