Think of the stomach as a balloon about three quarters full of acid.

Reflux is like letting the acid spill from the balloon. The more concentrated the acid that spills, the more damage it will do to whatever it spills on.

What can we do?

1. We can do something about the acid.

Antacids (eg. Tums) will dilute the acid. Typically they are chalk tablets, calcium carbonate, which reacts with the stomach's hydrochloric acid to produce a harmless salt (calcium chloride) plus carbon dioxide gas (which may cause you to burp) and water.

Alginates (eg. Gaviscon) float on the acid like oil on a stormy sea calming the waves to reduce the risk of spillage.

The effects of Antacids and alginates should be felt almost immediately.

To reduce the strength of the acid produced in the first place, there are two options:

H2 receptor antagonists (H2RA) (eg. Ranitidine). Acid is produced by the parietal cells in the lining of the stomach wall in response by messages carried by histamine to the H2 receptor cells. The antagonists block some of the messages reducing the acid content. (A bit like turning the faucet down.)

Proton pump inhibitors (PPI) (eg. Omeprazole). The membrane of the parietal cells lining the stomach, called proton pumps, promote the passage of protons creating the acid on the stomach side. PPIs block this action irreversibly. (A bit like capping the pipe.)

It takes about three days to replace these proton pumps.

PPIs are more effective than H2RAs and are effective for a longer period. The benefits of both of these types of drug are not felt immediately as they do not change the acid already present in the stomach.

2. We can do something about the reflux.

Thinking about the balloon analogy, you wouldn't want to squeeze the balloon or lay it down unless you closed the neck by squeezing it closed.

The stomach's entry is closed by a ring of muscles to squeeze it shut, called the lower esophageal sphincter (LES). For those suffering from reflux problems, the LES doesn't work as well as it should.

To avoid squeezing the stomach, tight clothing should be avoided and exercises that involve bending. Keeping upright as much as possible helps. Advice is to try raising the bedhead by 6 to 8 inches.

A Nissen fundoplication operation, usually performed laparascopically, takes the top part of the stomach (the fundus) and wraps it around the esophagus to reinforce the LES and prevent reflux.

A newer technology (called LINX) uses a band of magnets around the esophagus to provide an artificial LES. (It is not currently recommended for those with Barrett's.)

Chris (chairman@barrettswessex.org.uk)