Acid reflux is a common, yet complicated condition of the upper digestive tract. It can be managed through medication and lifestyle changes. But if left untreated, acid reflux can become very serious and even life-threatening. Dr. Constance A. Pietrzak, a gastroenterologist for a Chicago private practice, discusses the challenges of acid reflux and how it affects the body.
Dr. Constance A. Pietrzak
What causes acid reflux?
Acid reflux, or gastroesophageal reflux, results from the passage of gastric contents into the esophagus. Various factors work together to cause acid reflux. These include the potency of certain foods, the condition of the lining of the esophagus and the ability for contents to pass through the esophagus.
Most episodes of acid reflux are brief and do not cause symptoms or injury to the esophagus. However, when there is an imbalance of forces, patients may develop gastroesophageal reflux disease (GERD). The major cause for reflux is incompetence of the sphincter muscle at the junction where the esophagus and stomach meet.
Three mechanisms may play a role in weakening this anti-reflux barrier. First, under normal conditions, the lower esophageal sphincter (LES) functions to prevent backflow of gastric contents. The LES is a three to four centimeter long segment of smooth muscle where the esophagus meets the stomach. There are brief, random periods when the LES relaxes, and during these relaxations, backflow of contents can occur from the stomach up into the esophagus. This accounts for nearly all reflux events in patients with normal LES pressure. Second, a minority of patients may have a weak LES linked to a variety of causes, including gastric distention, certain foods, smoking, medications, and other medical conditions. Finally, anatomical abnormalities, such as a hiatal hernia can affect the function of the LES as well.
What are some common symptoms?
The most common symptoms are heartburn, regurgitation where patients perceive reflux of gastric acid and contents into their throat or mouth, and dysphagia, or difficulty swallowing. Other symptoms may include chest pain, sensation in the back of the throat, odynophagia or painful swallowing, nausea, cough, bronchospasm, hypersalivation, and belching.
Certain foods can act as triggers. Are there any other types of triggers?
While it is commonly seen that certain foods trigger acid reflux by affecting the anti-reflux barrier, this is not necessarily the case for all patients. Other triggers include lying in a reclining position too soon following a meal, late-night meals or snacks, eating large meals, smoking, alcohol, obesity and pregnancy.
Some common treatments include antacids, H-2 blockers and proton pump inhibitors. Can you explain how these work to treat reflux?** Antacids**, such as Tums, are used for as-needed symptom control. They do not prevent acid reflux from occurring. These neutralize the acidity of gastric juices, decreasing the acidity of contents that pass back up into the esophagus. This protects the lower esophagus from exposure to very acidic contents. They typically provide relieve of symptoms within five minutes and last 30 to 60 minutes.
Histamine blockers or H-2 blockers, such as ranitidine or famotidine, decrease acid secretion of acid-producing cells of the stomach by blocking the histamine-2 receptor. A decrease in acid secretion reduces the potential damage that can occur in the lower esophagus and improves symptoms. H-2 blockers have a slower onset than antacids, peaking at 2.5 hours, but can last from 4 to 10 hours.
Proton pump inhibitors (PPIs) are the most potent of the gastric acid inhibitors. They inhibit the Hydrogen-Potassium (H-K) ATPase pump of acid cells in the stomach. They should be taken 30 minutes before a meal. PPIs are used for prevention of acid reflux and should not be used for as-needed therapy. These have been shown to provide more effective relief than H-2 blockers of GERD symptoms.
What’s the difference between acid reflux, GERD, and Barrett’s Esophagus?
Acid reflux is the movement of gastric contents into the esophagus. Symptoms and esophageal injury occur when there is an imbalance of forces affecting anti-reflux barrier function. This results in gastroesophageal reflux disease (GERD).
Barrett’s esophagus refers to changes to cells lining the esophagus where the stomach meets the esophagus. With Barrett’s, normal esophageal-type cells change into gastric- type cells. This is referred to as intestinal metaplasia. Once these changes occur, there is an increased risk of progressing to precancerous cells, and ultimately for developing esophageal cancer, or esophageal adenocarcinoma (EAC). It is thought that chronic, or long standing, GERD may be a major cause for Barrett’s esophagus. Once Barrett’s is diagnosed, patients must undergo periodic upper endoscopy studies to monitor for potential dysplasia or EAC.
How do you know if you have reflux or just frequent heartburn?
Heartburn is defined as retrosternal, or chest, burning which typically occurs after a meal. Heartburn is a classic symptom of reflux and occurs as a result from passage of acidic gastric contents into the esophagus. The diagnosis of reflux can only be made clinically.
Diet plays an important role in managing acid reflux. What type of diet changes would you recommend?
First, avoid any trigger foods. Common foods to avoid include milk, caffeine, chocolate, citrus fruits, tomatoes and tomato products, alcohol, carbonated beverages, vinegar and salad dressings, and chewing gum. Second, avoid large meals or overeating. Eating frequent small meals throughout the day will reduce the risk for overeating, which increases the pressure on the LES from stomach contents.
Any other lifestyle changes you’d recommend?
I typically recommend weight loss, remaining upright for at least two hours after a meal, avoid late-night meals or snacks immediately before bed, smoking cessation and decreasing alcohol consumption.
What are the biggest concerns from a doctor’s standpoint of treating acid reflux?
Our goal in treating GERD is symptom control in order to improve patients’ quality of life. Many doctors worry about maintaining adequate control of reflux symptoms. If a patient fails traditional medical therapy, there is hesitation to move to surgery because that may place patients at unnecessary risk. Studies have shown that even after anti-reflux procedures symptoms often recur. Another major concern is the risk for Barrett’s and, ultimately, EAC in patients with long standing GERD.
What can people do to help their doctor treat them to the best of their ability?
Patients must do their best to be strict with dietary and lifestyle modifications, as this can drastically improve acid reflux. Patients should be compliant with any medication regimen. They should be sure they are taking medications appropriately. For example, PPIs need to be taken 30 to 60 minutes BEFORE a meal in order to maximize their effect.