There are many activities that we repeat every day in our lives, one of them is eating. Eating food is essential for our survival since it provides us with the necessary energy to do the chores of our daily life.
But how does that food get converted to energy that we can use? Well, you don’t have to worry about that. Mother Nature has it all covered. Nature has provided every human being with a digestive system (also called the alimentary canal, digestive tract or gut).
The digestive system first converts the large molecules in the food into small molecules. This process is called digestion. These small molecules are then absorbed from the intestines into the blood where it is distributed to all the organs to produce energy through various chemical pathways.
But the digestive tract is a long and complex system and sometimes things go wrong. Sometimes the stomach just doesn’t want any more food and throws it straight back up.
This reflux of gastric contents is called acid reflux or gastro-oesophageal reflux.
What Is Acid Reflux Disease?
When the stomach contents are refluxed back into the esophagus (the tube connecting the stomach to the throat), this condition is called acid reflux disease.
The stomach produces acid which makes the gastric contents (including the food, enzymes and other things present in the stomach) acidic. And since this acidic content has an acidic pH that is refluxed into the oesophagus, it is called acid reflux.
What Is Gastroesophageal Reflux Disease (Gerd)?
According to the Montreal consensus panel (44 experts),
“It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Troublesome means that the reflux interferes with the patient’s lifestyle”.
According to the American College of Gastroenterology,
“GERD is a condition when the patient presents with symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the oesophagus. This condition is chronic and relapsing”.
Are Acid Reflux Disease and Gerd the Same Thing?
Acid reflux is simply the state of having reflux of acidic gastric contents into the oesophagus. But you may not experience any symptoms or just very mild symptoms not enough to make you go to a doctor.
GERD is when this acid reflux lasts for more than a few weeks, damages the oesophagus and the symptoms are troublesome and interfere with your daily life and you make up your mind of seeing a doctor.
In simple words, as long as you have no symptoms or very mild symptoms and you have not seen a doctor, it is just acid reflux. When the symptoms start to interfere with your lifestyle and you end up seeing a doctor, it is called GERD.
GERD is the clinical form of acid reflux disease. GERD is the name that is present in medical literature to describe reflux of gastric contents in the oesophagus and it is what the doctors will write in the patient’s file.
Why Does Gastric Acid Damage the Oesophagus and Not the Stomach?
The acid released in the stomach is hydrochloric acid with a pH of 2. It is very strong and can burn your flesh if dip your finger in it. Then why does it not damage the stomach?
The acid can potentially damage the stomach. But to prevent this, nature has provided it with several defences against the acid.
First is that the stomach cells produce a protective layer of mucin (proteins + carbohydrates) over their surface that prevents the acid from touching the stomach cells.
The stomach also secretes bicarbonates (that are alkaline in nature) to buffer the gastric acid. If somehow, some amount of acid leaks through layers of the stomach wall, the blood vessels present in the stomach will take away these protons and decrease the pH.
And if some cells of the inner surfaces of the stomach are somehow damaged, these cells will simply regenerate from the remaining cells. Prostaglandins are small lipid-like molecules that also help in the protection of the stomach from acid.
But unfortunately, the oesophagus does not have these defence mechanisms and is thus susceptible to damage by gastric acid.
Causes of Acid Reflux Disease:
The lower oesophagal sphincter (LES) is present at the junction of the oesophagus and stomach. It acts as a valve and prevents the backflow of gastric contents into the oesophagus. Gastroesophageal reflux (GER) occurs when LES is not functioning properly. It can be due to the following causes:
1. Abnormalities of the lower oesophagal sphincter: Lower oesophagal sphincter is the most important factor in GER. People have GER because the LES in them have decreased tone and is not tight enough to prevent the backflow of gastric contents.
In others, basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation.
2. Hiatal hernia: Hiatal hernia is the herniation of the stomach through the diaphragm into the chest. The diaphragm is a muscle that separates the abdominal cavity from the chest.
However, it has openings in it for the passages of the oesophagus, blood vessels and nerves. A sliding hiatal hernia is when the stomach herniates through the oesophagal foramen. But how is all this related to GER? Hiatal hernia is associated with acid reflux disease because it interferes with the normal functioning of the lower oesophagal sphincter.
Hiatus hernia causes reflux because the pressure gradient between the abdominal and thoracic cavities is lost which normally pinches the hiatus. In addition, the oblique angle between the cardia (a part of the stomach) and oesophagus disappears.
3. Defective oesophagal clearance: If for some reason, gastric contents are refluxed into the oesophagus, the movement of the oesophagal muscles will push that content back into time. But if you have a problem in the muscles of the oesophagus and thus defective oesophagal clearance, the reflux gastric content will remain in the oesophagus for a longer period.
And the longer the acidic gastric content remains in the stomach, the more damage it does to the oesophagus. Thus, you have a high chance of developing GERD if you have defective oesophagal clearance.
4. Delayed gastric emptying: After the stomach has mixed the food and enzymes well enough, it passes it to the duodenum (first part of the small intestine) and empties itself to allow entry of food from the oesophagus. Delayed gastric emptying is present in patients with gastroesophageal reflux disease. The reason is unknown.
5. Increased intra-abdominal pressure: Conditions that increase intra-abdominal pressure are established predisposing causes of acid reflux disease. These conditions include obesity and pregnancy.
6. Acid indigestion: Excessive (more than needed) secretion of gastric acid by stomach cells is called acid indigestion. It is also called hyperchlorhydria or acidity in the stomach. Stomach acid is the most important oesophagal irritant and there is a strong relationship between acid exposure time and symptoms.
So, if you have excessive secretion of gastric acid, there will be more damage to the oesophagal by acid reflux and you are more likely to develop GERD.
7. Dietary and environmental factors: When there is some disease of the digestive tract, diet almost always has a role in it. Acid reflux disease is no different. Dietary fat, chocolate, coffee, tea and alcohol relax the lower oesophagal sphincter and may provoke symptoms.
These foods are not the only ones. Foods that trigger symptoms vary widely between individuals and may include other kinds of foods.
8. Patient factors: Visceral sensitivity and patient vigilance play an important role in determining symptoms severity and consulting behaviour in individual patients.
What Are the Symptoms?
GERD symptoms can be divided into
Esophageal: These symptoms include:
Heartburn means a burning sensation behind the breastbone (sternum) or ribs. It is often provoked after eating, straining, bending or lying down and in the evening. Heartburn is the most common symptom of GERD.
The second most common symptom of GERD is the regurgitation of swallowed food from the stomach or oesophagus to the mouth with nausea or forceful contractions of abdominal muscles.
3. Abdominal pain
GERD can also present in the form of pain in the abdomen. The acid reflux pain area is in the midline just below the ribcage (the epigastric region). The pain may sometimes travel up to the chest and throat.
Dysphagia means difficulty in swallowing food. This symptom occurs late in the course of the disease and indicates serious damage to the oesophagus.
Odynophagia is the condition when swallowing is painful. This also occurs late in the course of the disease and indicates severe GERD.
Belching or burping is emitting noisy sounds from the stomach or oesophagus through the mouth.
Extra oesophagal: These symptoms include:
Cough is a common extra oesophagal symptom and indicates that you may have acid reflux during the nighttime or sleeping.
Wheezing means whistling sound during breathing.
3. Hoarseness of voice
The refluxed acid may reach the larynx, damaging it and causing hoarseness of voice.
4. Sore throat
All the acid damaging the throat can cause discomfort in the throat or sore throat. Also, damage to the throat provides fertile soil for bacteria and viruses to invade and cause infection which can also cause hoarseness of voice.
5. Globus sensation
Globus sensation or Globus pharyngeus is the feeling of a lump in the throat when there is nothing like that present. People might confuse the globe with a foreign body stuck in the throat or cancer in the throat.
These conditions will cause difficulty in swallowing and breathing while the globus will not be accompanied by such symptoms.
6. Atypical chest pain
The chest pain may be severe and can mimic angina or heart attack. But it is not caused by a problem in the heart. It is caused by the spasm of the oesophagal muscle in response to acid reflux.
How Do I Know If I Have Gerd?
Occasional episodes of gastroesophageal reflux are common in healthy individuals. Reflux is normally followed by oesophagal peristaltic waves that efficiently clear the gullet, alkaline saliva neutralizes residual acid and symptoms do not occur. Gastro oesophagal reflux disease develops when the oesophagal mucosa is exposed to gastroduodenal contents for prolonged periods, resulting in symptoms.
It means if you experience one or two episodes of reflux of food, it does not mean that you have GERD. But if these episodes are reoccurring more than twice a week, then you should seek medical care because you may have GERD.
What Are the Complications?
Severe GERD may cause the following complications:
1. Esophagitis: Esophagitis means inflammation of the oesophagus. The acid from the stomach causes necrosis (death) of the cells of the oesophagus. This cell death will trigger inflammation in the oesophagus.
2. Barrett’s oesophagus: What do you do when are facing a lot of stress? You to try to adapt, change yourself and somehow deal with it. Acid reflux is like stress for the oesophagus.
The way the oesophagal cells deal with this stress is that they change their cell type to those of the cells of the intestine because intestinal cells are made to tolerate stomach acid very well. This change of cell type is called metaplasia. Change of cell type of oesophagal cells to intestinal cells in response to acid reflux is called Barrett’s oesophagus.
So, oesophagal cells found a way to minimize damage by gastric acid, then how is Barrett’s oesophagus a bad thing? It is bad because Barrett’s oesophagus is a pre-cancerous condition. Cell metaplasia is the first step in the pathogenesis of cancer. The relative risk of oesophagal adenocarcinoma increases 40 to 120 folds in the presence of Barrett’s oesophagus.
3. Oesophagus cancer: Barrett’s oesophagus is a pre-malignant condition and can lead to adenocarcinoma of the lower one-third of the oesophagus.
4. Anaemia: Iron deficiency anaemia can occur as a consequence of occult blood loss from long-standing esophagitis.
5. Benign oesophagal stricture: One of the fascinating things about our body is that it can heal after suffering damage. But when it cannot heal completely, the healing process causes fibrosis and stricture formation.
Fibrous strictures can develop as a consequence of longstanding esophagitis, especially in the elderly and those with poor oesophagal peristaltic activity.
6. Gastric volvulus: Occasionally, a massive intrathoracic hiatus hernia may twist on itself, leading to a gastric volvulus. This gives rise to complete oesophagal or gastric obstruction and the patient presents with severe chest pain, vomiting and dysphagia.
How Does My Lifestyle Affect Gerd?
Like in many other diseases, lifestyle also has a role in GERD. Your lifestyle can increase or decrease your chances of developing GERD. Lifestyle is also a factor in determining the severity of symptoms and complications.
Following are the various lifestyle-related risk factors of GERD:
1. Smoking: Cigarette smoke is an irritant and contains multiple carcinogens. This can lead to oesophagal cancer. Also, nicotine interferes with the contraction of oesophagal muscles.
2. Obesity: Increased weight increases intra-abdominal pressure that can lead to acid reflux.
3. Eating large meals: If you eat large meals, then it would take longer for the stomach to digest it and pass it down to the intestine. This delays gastric emptying and delayed gastric emptying is associated with acid reflux.
4. Eating late at night: If you eat late at night and go to sleep soon after it, then that food will not be very well digested. It is because while sleeping, your body rests and repairs the wear and tear it has endured during the whole day.
But if you will force the stomach to digest food when it is supposed to rest, the digestion will be very effective.
5. Lying down after a meal: Although the food is moved along the digestive tract by the contraction of its muscles, gravity also helps. When you lie down after a meal, that help from the gravity disappears and the muscles will have a hard time moving the food down the oesophagus.
6. Alcohol: Alcohol interferes with the normal functioning of the lower oesophagal sphincter and thus is a risk factor for GERD.
7. Tea and coffee: Caffeine beverages like tea and coffee relaxes the lower oesophagal sphincter and increase the chances of acid reflux into the oesophagus.
8. Dietary choices: Eating lots of chocolates, fried foods and other fatty foods increases the chances of GERD. These foods take a long time in passing from the stomach to the intestine thus delaying gastric emptying. Eating spicy foods is also a risk factor.
9. Sedentary lifestyle: Exercise helps our body remain healthy. But you do not do much exercise and live a sedentary lifestyle; you have higher chances of developing GERD.
10. Medications: Long term use of NSAIDs (ibuprofen, diclofenac) for gout, calcium channel blockers (verapamil) for blood pressure, and muscle relaxants is also a risk factor.
Other risk factors:
Risk factors other than lifestyle are:
1. Hiatal hernia
3. Connective tissue disorders such as scleroderma
5. Gut motility disorders
How is it diagnosed?
Following investigations are used for the diagnosis of GERD. Although the doctor can make the diagnosis based on your symptoms (because good doctors simply listen to the patient), these investigations are done to assess the severity of the disease.
1. Electrocardiography: Although not much common, chest pain can be a symptom of GERD. But if you go to the doctor with the complaint of chest pain, the first thing that would come into their mind will be a heart attack and they are likely to order an ECG to exclude this cause.
It is important because chest pain is more common with a heart attack than GERD and GERD is not very life-threatening until it is very severe, but a heart attack is a medical emergency.
2. CBC and iron levels: If the doctors think that your symptoms are due to GERD, they may ask for a CBC and serum iron levels to check whether you have anaemia or not. This will tell them about the severity and emergency of the disease.
3. Barium swallow: It is a useful first diagnostic test especially if you have difficulty in swallowing. This is used to find any stricture, mass or hiatal hernia.
4. Endoscopy: It is the investigation of choice for GERD. It will be done if you are over the age of 50-55 years or have alarming signs like weight loss, anaemia, dysphagia and early satiety.
5. 24-hour pH monitoring: If the doctor is not sure about the diagnosis, 24 hour pH monitoring can help a lot. In this investigation, pH changes in your oesophagus are recorded for 24 hours. If you have acid reflux, the recordings will show acidic pH.
6. Oesophagal manometry: This test is done to check the LES pressure and peristaltic (rhythmic muscle contractions) movements of the oesophagus.
Can I Self-test at Home?
You cannot self-test and diagnose yourself at home. You can have an opinion about what might be the diagnosis but you should consult a doctor for definitive diagnosis and treatment.
What is the Treatment?
Medical treatment: Medical treatment of GERD includes:
1) Antacids: Antacids are weak alkalis that neutralize the stomach acid. They are dissolved in a glass of water and they give you quick relief from heartburn. Some common antacids are Gaviscon and Eno.
2) H2 blockers: These medications are acid-suppressing agents. These drugs decrease the secretion of acid in the stomach. These include cimetidine, ranitidine and famotidine.
3) Proton pump inhibitors (PPIs): These are also acid-suppressing agents but are stronger than H2 blockers. They also decrease acid production in the stomach. Common proton pump inhibitors are Omeprazole, esomeprazole and pantoprazole.
4) Prokinetic drugs: These drugs improve the contraction of the muscles of the oesophagus. These include metoclopramide, Gimoti, Reglan.
· Surgical treatment: Surgery is done in case of failure of medical treatment, presence of complications or the patient prefers to have surgery. Anti-reflux surgeries include:
1) NISSEN fundoplication: In fundoplication, the surgeon wraps the top of your stomach around the lower oesophagal sphincter. This tightens the muscle and prevents reflux. The wrapping of the stomach can be complete or partial called complete fundoplication and partial fundoplication respectively.
This is a minimally invasive procedure done through a laparoscopic approach. Laparoscopic means that instruments are inserted through small incisions made on your body rather than opening the abdomen with a large incision.
2) LINX device: LINX device is a ring of tiny magnetic beads. These beads are tied around the junction of the oesophagus and stomach. The magnetic attraction is balanced such that it is strong enough to prevent reflux of gastric contents but weak enough to allow the entry of food into the stomach.
Like fundoplication, it is also inserted through minimally invasive surgery. However, you should be careful about getting an MRI. MRI machine is a powerful magnet that can pull these magnet beads and cause serious damage to the abdomen. So if you have this surgery, you should avoid getting an MRI.
Lifestyle modifications: Along with treatment, lifestyle modifications are also necessary for acid reflux cure. The lifestyle modifications include:
1) Quit smoking
2) Quit alcohol
4) Minimize the use of tea and coffee
5) Avoid fried foods and spicy things (follow the GERD diet as instructed by the doctor)
6) Do not lie down after eating
7) Eat dinner 2-3 hours before sleeping
8) Do not eat very large meals
9) Maintain a healthy weight
When to See a Doctor?
You should seek medical care if:
1. You have sudden onset chest pain with difficulty in breathing
2. Severe symptoms that interfere with your daily life
3. Episodes of heartburn more than twice a week
What Are the Other Treatment Options or Home Remedies?
If you having an acid reflux attack (woke up from sleep feeling severe heartburn, abdominal discomfort and cough), the following remedies can give you relief:
1. Elevate your upper body using a wedge pillow
2. Try ginger tea or add grated or diced ginger to your food
3. If you are wearing tight clothing, change and wear loose clothes
4. Stand straight up if you were lying down or in a bending position
5. Sip apple cider vinegar
6. Take liquorice supplements
7. Use chewing gum
8. Take over-the-counter medications (PPIs, H2 blockers, antacids)
Asthma and Acid Reflux Disease:
Asthma and acid reflux are related to each other. More than 75% of people with asthma have GERD. They are twice as likely to have GERD as people without asthma.
GERD makes asthma symptoms worse and asthma drugs can cause GERD. GERD can flare up asthma symptoms as the refluxed acid contents may enter the airway irritating the bronchi and lungs.
Acid Reflux Disease and Pregnancy:
As the foetus grows in size, it pushes the other organs in the abdomen. This increases the intra-abdominal pressure. As increased intra-abdominal pressure causes acid reflux, women are at risk of developing acid reflux disease during pregnancy.
But don’t worry, since the disease was caused by pregnancy, it will go away once the baby is delivered and the uterus comes back to its normal size.
What are the symptoms of acid reflux disease? What are the treatment options? How can I prevent it? Is it related to pregnancy and asthma? Learn that and more about acid reflux disease.