Acid reflux

Page last reviewed: 13/07/2011

Gastro-oesophageal reflux disease (GORD) is a common condition where stomach acid leaks out of the stomach and into the oesophagus (gullet).

Symptoms of GORD include:

  • heartburn - burning chest pain or discomfort that occurs after eating
  • an unpleasant sour taste in the mouth caused by the stomach acid coming back up into the mouth (this is known as regurgitation)
  • difficulty swallowing (dysphagia)

The symptoms of GORD can range from mild to severe.

Lower oesophageal sphincter (LOS)

It is thought that GORD is caused by a combination of factors. The most important factor is a muscle called the lower oesophageal sphincter (LOS) not working properly.

The LOS acts like a valve. It opens to let food fall into the stomach, and closes to prevent acid leaking out of the stomach and into the oesophagus. In cases of GORD, the LOS does not close properly. It allows acid to leak up out of the stomach.

How common is GORD?

GORD is a very common digestive condition. It is estimated that around 1 in 5 people will have at least one episode of GORD a week.

GORD can affect people of all ages, including children. The condition is twice as common in men as it is in women.

Known risk factors for GORD include:

  • being overweight or obese
  • being pregnant
  • eating a high-fat diet

Outlook

The outlook for GORD is generally good, and most people respond well to treatment with medication.

However, relapses are common. Around half of people experience a return of symptoms after a year. As a result, some people may need a long-term course of medication to control their symptoms.

A small number of people with GORD do not respond to medication and need surgery to treat their symptoms.

More serious cases of GORD can trigger a range of complications, such as:

  • oesophageal ulcers (open sores that develop in the lining of the oesophagus)
  • bleeding of the oesophagus
  • mouth-related problems, such as tooth decay, gum disease and bad breath

Page last reviewed: 13/07/2011

Common symptoms

The three most common symptoms of gastro-oesophageal reflux disease (GORD) are:

  • heartburn
  • regurgitation of acid into your throat and mouth
  • difficulty swallowing (dysphagia)

These symptoms are discussed in more detail below.

Heartburn

Heartburn is a burning pain or a feeling of discomfort that develops just below your breastbone. The pain is usually worse after eating or when bending over or lying down.

Regurgitation

Regurgitation of acid usually causes an unpleasant, sour taste at the top of your throat or the back of your mouth.

Dysphagia

Around 1 in 3 people with GORD has problems swallowing (dysphagia). It can occur if the stomach acid causes scarring of the oesophagus, which leads to the oesophagus narrowing and making it difficult to swallow food.

People with GORD-associated dysphagia say it feels like a piece of food has become stuck somewhere near their breastbone.

Less common symptoms of GORD

GORD can sometimes have a number of less common symptoms that are associated with the irritation and damage that are caused by stomach acid.

Less common symptoms of GORD include:

  • pain when swallowing
  • nausea
  • persistent cough
  • tooth decay
  • laryngitis (inflammation of the larynx), which causes throat pain and your voice to become hoarse

If you have asthma and GORD, your asthma symptoms may get worse as a result of the stomach acid irritating your airways.

Page last reviewed: 13/07/2011

In many cases of gastro-oesophageal reflux disease (GORD) there is no reason why a person develops the condition.

However, one of the known causes of GORD is a problem with a muscle, known as the lower oesophageal sphincter (LOS), which is located at the bottom of the oesophagus (gullet).

The LOS works in a similar way to a valve. It opens to let food into your stomach, and it closes to prevent any acid leaking back up into your oesophagus.

However, in people with GORD, the LOS can become weakened, which allows stomach acid to pass back into the oesophagus. This causes the symptoms of heartburn, such as a burning pain or a feeling of discomfort in your stomach and chest.

Other causes of GORD can include:

  • an increased pressure on your stomach as a result of being overweight or obese
  • your stomach taking longer than it should to dispose of stomach acid, a condition that is known as gastroparesis

Gastroparesis is common in people who have diabetes because high blood sugar levels can damage the nerves that control the stomach.

Risk factors

A number of possible risk factors are known to increase your likelihood of developing GORD. These include:

  • being overweight or obese - for the reasons mentioned above
  • having a diet that is high in fatty foods - the stomach takes longer to dispose of stomach acids after digesting a fatty meal
  • using tobacco, alcohol, coffee or chocolate - it has been suggested that these four substances may relax the LOS
  • being pregnant - the changes in hormone levels during pregnancy can weaken the LOS and increase the pressure on your stomach
  • having a Hernia, hiatus- a hiatus hernia is where part of your stomach pushes up through your diaphragm (the muscle that is used for breathing)
  • stress

There are a number of medications that can relax the LOS, leading to the symptoms of GORD.

These include:

  • anticholinergics - a type of medication that is used to treat a wide range of respiratory (lung), digestive, neurological (nerve) and infectious conditions
  • calcium-channel blockers - a type of medication that is used to treat high blood pressure (hypertension)
  • theophylline - a type of medication that is used to treat respiratory conditions, such as asthma and chronic pulmonary obstructive disorder (COPD) (a general term that describes a collection of serious lung diseases, such as emphysema)
  • benzodiazepines - a type of tranquiliser that is used to treat serious panic and anxiety disorders
  • nitrates - a medication that is used to treat angina (a condition that causes chest pain).

Page last reviewed: 13/07/2011

In most cases, your GP will be able to diagnose gastro-oesophageal reflux disease (GORD) by asking you some questions about your symptoms.

Further testing for GORD is usually only required if:

  • you are having difficulty swallowing (dysphagia)
  • your symptoms do not improve despite taking medication

Further testing aims to confirm or disprove the diagnosis of GORD while checking for any other possible causes of your symptoms, such as cancer of the oesophagus.

Endoscopy

An endoscopy is a procedure where the inside of your body is directly examined using a piece of medical equipment that is known as an endoscope.

An endoscope is a long, thin flexible tube that has a light source and a video camera at one end so that images of the inside of your body can be sent to an external monitor.

To confirm a diagnosis of GORD, the endoscope will be inserted into your mouth and down your throat. The procedure is usually done while you are awake, and you may be given a sedative to help you to relax.

An endoscopy is used to check whether the surface of your oesophagus has been damaged by stomach acid. It can also rule out more serious conditions that can also cause heartburn, such as stomach cancer.

Manometry

If an endoscopy does not find any evidence of damage to your oesophagus, you may be referred for a further test called manometry.

Manometry is used to assess how well your lower oesophageal sphincter (LOS) is working by measuring pressure levels inside the sphincter muscle.

During manometry, one of your nostrils will be numbed using a topical anaesthetic. A small tube will then be passed down your nostril and into your oesophagus to the site of the LOS. The tube contains a number of pressure sensors, which can detect the pressure that is generated by the muscle, then send the reading to a computer.

During the test, you will be asked to swallow some food and liquid to check how effectively your LOS is functioning.

A manometry test takes around 20 to 30 minutes to complete. It is not painful, but you may have some minor side effects including:

  • a nosebleed
  • a sore throat

However, these side effects should pass quickly once the test has been completed.

Manometry can be useful for confirming a diagnosis of GORD, or for detecting less common conditions that can disrupt the normal workings of the LOS, such as muscle spasms or achalasia (a rare swallowing disorder).

24-hour pH monitoring

If the manometry test cannot find any problems with your oesophageal sphincter muscles, another test known as 24-hour pH monitoring can be used (pH is a unit of measurement that is used in chemistry, and describes how acidic a solution is). The lower the pH level, the more acidic the solution is.

The 24-hour pH monitoring test is designed to measure the pH levels around your oesophagus. You should stop taking any medication that is used to treat GORD for seven days before having a 24-hour pH test because the medication could distort the test results.

During the test, a small tube containing a probe will be passed through your nose to the back of your oesophagus. This is not painful but it can feel a little uncomfortable.

The probe is connected to a portable recording device that is about the size of a MP3 player, which you wear around your wrist. Throughout the 24-hour test period, you will be asked to press a button on the recorder every time you become aware of your symptoms.

You will be asked to complete a diary sheet by recording when you have symptoms upon eating. Eat as you normally would to ensure that an accurate assessment can be made.

After the 24-hour period is over, the probe will be removed so that measurements on the recorder can be analysed. If the test results indicate a sudden raise in your pH levels after eating, a confident diagnosis of GORD can usually be made.

 

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Page last reviewed: 13/07/2011

Self-care

There are a number of self-care techniques that may help to relieve the symptoms of gastro-oesophageal reflux disease (GORD). They are described below.

  • If you are overweight, losing weight may help to reduce the severity and frequency of your symptoms because it will reduce the pressure on your stomach.
  • If you are a smoker, you should consider quitting. Tobacco smoke can irritate your digestive system and may make the symptoms of GORD worse.
  • Eat smaller, more frequent meals rather than three large meals a day. Make sure that you have your evening meal three to four hours before you go to bed.
  • Be aware of triggers that make your GORD worse. For example, alcohol, coffee, chocolate, tomatoes, or fatty or spicy food. After you identify any food that triggers your symptoms, remove them from your diet to see whether your symptoms improve.
  • Raise the head of your bed by placing a piece of wood or blocks under it. This may help to reduce your symptoms of GORD. However, make sure that your bed is sturdy and safe before adding the wood or block. Do not use extra pillows because this may increase the pressure on your abdomen.

If you are currently taking medication for other health conditions, check with your GP or pharmacist to find out whether they may be contributing to your symptoms of GORD. Alternative medicines may be available. Do not stop taking a medication that has been prescribed without consulting your GP first.

Medication

A number of different medications can be used to treat GORD. These include:

  • over-the-counter (OTC) medications
  • proton-pump inhibitors (PPIs)
  • H2-receptor antagonists
  • prokinetics

These are described below.

Over-the-counter (OTC) medications

A number of over-the-counter (OTC) medicines can help to relieve the symptoms of mild to moderate GORD.

Antacids are medicines that neutralise the effects of stomach acid. However, antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed into your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates are an alternative type of medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

Some PPIs and H2 Receptor antagonists (discussed below) are also available without prescription from your pharmacist. These  are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist whether these medicines are suitable for you.

Proton-pump inhibitors (PPIs)

If GORD fails to respond to the self-care techniques described above, your GP may prescribe a one month course of proton-pump inhibitors (PPIs) for you. PPIs work by reducing the amount of acid that is produced by your stomach.

Possible side effects of PPIs include:

  • headaches
  • diarrhoea
  • nausea
  • abdominal pain
  • constipation
  • dizziness
  • skin rashes

The side effects of PPIs are usually mild and should stop once you have finished taking them. In order to minimise any side effects, your GP will prescribe the lowest possible dose of PPIs that they think will be effective in controlling your symptoms. Therefore, inform your GP if they prescribe PPIs for you that prove to be ineffective. A stronger dose may be needed.

Sometimes, the symptoms of GORD can return after a course of PPIs has been completed. Go back to see your GP if you have further or persistent symptoms. 

H2-receptor antagonists

If PPIs cannot control your symptoms of GORD, another medicine known as a H2-receptor antagonist (H2RA) may be recommended to take in combination with PPIs on a short-term basis (two weeks), or as an alternative to them.

H2RAs block the effects of the chemical histamine, which is used by your body to produce stomach acid. H2RAs therefore help to reduce the amount of acid in your stomach.

Side effects of H2RAs are uncommon. However, possible side effects may include:

  • diarrhoea
  • headaches
  • dizziness
  • tiredness
  • a rash

Prokinetics

If your GORD symptoms are particularly severe and they are not responding to other forms of treatment, your GP may prescribe a short-term dose of a prokinetic.

Prokinetics speed up the emptying of your stomach, which means that there is less opportunity for acid to irritate your oesophagus. However, the long-term use of prokinetics is not recommended. It is likely that you will only be advised to take them if your symptoms are particularly severe.

Around 1% of people who take prokinetics have what is known as 'extrapyramidal symptoms'. Extrapyramidal symptoms are a series of related side effects that affect your nervous system.
Extrapyramidal symptoms include:

  • muscle spasms
  • problems opening your mouth fully
  • a tendency to stick your tongue out of your mouth
  • slurred speech
  • abnormal changes in body posture

If you have the above symptoms while taking prokinetics, stop taking them and contact your GP or out-of-hours doctor immediately. They may recommend that your dose is discontinued.
Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn.

Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms. The use of prokinetics is also not recommended for pregnant or breastfeeding women.

Surgery

Surgery is usually only recommended in cases of GORD that fail to respond to the treatments listed above.

Alternatively, you may wish to consider having surgery if you have persistent and troublesome symptoms but you do not want to take medication on a long-term basis.

While surgery for GORD can help to relieve your symptoms, there are some associated complications that may result in you developing additional symptoms, such as:

  • difficulty swallowing (dysphagia)
  • flatulence (the excessive passing of wind)
  • bloating
  • an inability to belch (burp)

Discuss the advantages and disadvantages of surgery with your GP before making a decision about treatment.

Surgical procedures that are used to treat GORD include:

  • laparoscopic nissen fundoplication (LNF)
  • endoscopic injection of bulking agents
  • endoluminal gastroplication
  • endoscopic augmentation with hydrogel implants
  • endoscopic radiofrequency ablation

These procedures are discussed below.

Laparoscopic nissen fundoplication (LNF)

Laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques that is used to treat GORD.

LNF is a type of keyhole surgery that involves the surgeon making a series of small incisions (cuts) in your abdomen (tummy). Carbon dioxide gas is then used to inflate your abdomen in order to give the surgeon room to work in.

During LNF, the surgeon will wrap the upper section of your stomach around your oesophagus and staple it in place. This will contract (tighten) your lower oesophageal sphincter (LOS), which should prevent any acid moving back out of your stomach.

LNF is carried out under general anaesthetic, which means that you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job that you do, you should be able to return to work within three to six weeks.

For the first six weeks after surgery, it is recommended that you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include:

  • difficulty swallowing (dysphagia)
  • belching (burping)
  • bloating
  • flatulence (the excessive passing of wind)

These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.

New surgical techniques

In the last decade, a number of new surgical techniques have been introduced for the treatment of GORD.

In the UK,the National Institute for Health and Clinical Excellence (NICE) has looked at a number of these surgical techniques. It has recommended that they are safe enough to be made available.

However, NICE has also recommended that people who are considering having these new techniques should be made aware that there is little evidence regarding their effectiveness in the medium- to long-term.

Lifestlye changes and self management should be the key consideartions for any patient with the symptoms of GORD

Page last reviewed: 13/07/2011

Oesophageal ulcers

The excessive acid that is produced by gastro-oesophageal reflux disease (GORD) can damage the lining of your oesophagus and eventually lead to the formation of ulcers. The ulcers can bleed, causing pain and making swallowing difficult. Ulcers can usually be successfully treated by controlling the underlying symptoms of GORD.

The medications that are used to treat GORD can take several weeks to become effective, so it is likely that your GP will recommend some additional medication to provide short-term relief from your symptoms.

Two types of medication that can be used are:

  • antacids to neutralise stomach acid on a short-term basis
  • alginates, which produce a protective coating on the lining of your oesophagus

Both antacids and alginates are over-the-counter (OTC) medications that are available from pharmacists. The pharmacist will be able to advise you about which particular types of antacid and alginate are most suitable for you.

Antacids are best taken when you have symptoms, or when symptoms are expected, such as after meals or at bedtime. Alginates are best taken after meals.

Side effects for both medications are uncommon but include:

  • diarrhoea
  • vomiting
  • flatulence (wind)

Oesophageal stricture

Repeated damage to the lining of your oesophagus can lead to the formation of scar tissue. If the scar tissue is allowed to build up, it can cause your oesophagus to become narrowed. This is known as oesophageal stricture.

An oesophageal stricture can make swallowing food difficult and painful. Oesophageal strictures can be treated by using a tiny balloon to widen (dilate) the oesophagus. This procedure is usually carried out under a local anaesthetic.

Barrett's oesophagus

Repeated episodes of GORD can lead to changes in the cells of the lining of your lower oesophagus. This is a condition known as Barrett's oesophagus.

It is estimated that 1 in 10 people with GORD will develop Barrett's oesophagus. Most cases of Barrett's oesophagus first develop in people who are between 50 and 70 years old. The average age at diagnosis is 62.

Barrett's oesophagus does not usually cause any noticeable symptoms other than those that are associated with GORD. However, there is a small risk that the cells that are affected by Barrett's oesophagus could turn cancerous and trigger the onset of oesophageal cancer. Regular checks may be recommended by your specialist in some cases.

Oesophageal cancer

Each year it is estimated that 1 in every 200 people with Barrett's oesophagus develop oesophageal cancer. Risk factors that increase the risk of the cells in the lining of your oesophagus turning cancerous include:

  • being male
  • having the symptoms of GORD for longer than 10 years
  • having three or more episodes of heartburn and related symptoms a week
  • smoking
  • obesity

If it is thought that you have an increased risk of developing oesophageal cancer, it is likely that you will be referred for regular endoscopies in order to monitor the condition of the affected cells.

If oesophageal cancer is diagnosed in its initial stages, it is usually possible to cure the cancer using a type of treatment called photodynamic therapy (PDT).

PDT involves injecting your oesophagus with a special type of medication that makes it very sensitive to the effects of light. A laser that is attached to an endoscope is placed inside your oesophagus and burns away the cancerous cells.

See the Health A-Z topic about Cancer of the oesophagus for more information.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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