What you need to know about acid reflux: symptoms, diagnosis, treatment

Today we’re going to move away from butts, and go way higher, to the chest and epigastrium: we’re going to discuss acid reflux, because it seems to be acid reflux day at my office.

First, let’s get one very important thing out of the way.  It is acid refLUX, not acid refLEX.

ReFLUX – the flowing back of a liquid, especially that of a fluid in the body

ReFLEX – an action that is performed as a response to a stimulus and without conscious thought.

Some other things we should get out of the way, syntax-wise.  Gastro-esophageal reflux (refLUX) disease (otherwise known as GERD, pronounced like curd) is sometimes interchangeable with acid reflux, though on occasion, it can refer to non-acid reflux, which is not as common.  Heartburn is one of the symptoms you can get from acid reflux.  Esophagitis is inflammation in the esophagus (food pipe) that is a sign of GERD.

Reflux, reflex…. what is it, anyway?

It’s basically acid/stomach juice backing up and splashing into your esophagus, and causing discomfort.  Some amount of splashing is normal; it keeps the esophagus clean, but vigorous splashing will cause irritation and inflammation.

courtesy of Medtronic

I think I have it.  What are the symptoms?

The most typical and common symptom is heartburn.  If you have to ask, “what’s heartburn?” then, you’ve never had heartburn.  It’s very unpleasant.  It’s a burning or sour sensation in the pit of your stomach and up the middle of your chest.  Other less typical symptoms include cough, sore throat, chest pain, belching, bloating, hiccups, and trouble swallowing or feeling like food is sticking.

But WHY!  Why would the powers that afflict us with this ?

There are two mechanisms. 1) You produce too much acid, and 2) the little muscle that separates the esophagus from the stomach is weak.  It’s called a sphincter (go ahead, haver yourself a chuckle, but only one.  “Sphincter” refers to any circular muscle that’s supposed to keep an opening closed in the body, and not just the anus), or more specifically, the lower esophageal sphincter (LES).

There are certain conditions that predispose you to acid reflux.

  • pregnancy
  • obesity
  • being a white male smoker

Also certain behaviors can trigger it.

  • Eating large meals or lying down right after a meal
  • Being overweight or obese
  • Eating a heavy meal and lying on your back or bending over at the waist
  • Eating certain foods, such as citrus, tomato, chocolate, mint, garlic, onions, or spicy or fatty foods
  • Caffeine (that includes soda and tea)
  • Tight clothing (for real)
too much exercise?! I knew exercise was bad for you!

What are we going to do about this?

In the past, treating acid reflux was a serious problem.  People would take Tums all the time, drink milk, eat baby food, and even have surgery.  Then they came out with some medications that work magically well, and now everyone in America takes them so they can eat their Doritos and not suffer the consequences, at least reflux-wise.  I can’t speak for waist-line wise.

  • Antacids – acid neutralizers like Tums and Rolaids.  These are only for intermittent symptom relief.  If you find yourself popping Rolaids more than just once in a while, get thee to a doctor.
  • H2 blockers – Zantac, Pepcid, Tagamet.  They block histamine release, which is one of the mechanisms that triggers production of acid.  They work ok for mild cases
  • Proton pump inhibitors (PPI) – Prilosec, Protonix, Prevacid, Nexium, Aciphex, Zegerid (with an antacid).  These turn off the pump that produces acid altogether, and work really well
  • A combination of the two – if your reflux is extra stubborn
  • Surgery – if it’s reflux that won’t respond to medications, and it’s truly really reflux, you may get referred for surgery.  It’s called “Nissen fundoplication” and it involves tying the very top of the stomach around the bottom of the esophagus to make it tighter.  It used to be done fairly frequently, but the pills work so well, that only specialized centers do them now, and even that reluctantly

PPIs, I remember reading about them, they’re bad now, right?

Weeeeellll…. That depends. No medication is great and you should always be on the smallest recommended dose that works.  And, like I said, everybody in America is on a PPI, so I definitely think there is overuse of the drugs on people who probably don’t need them.  However, the studies that made such a splash in regards to PPIs causing Alzheimer’s, kidney problems, heart attacks – these were very small, very poor quality studies that I don’t think actually prove causality.  There is an increased risk of C diff (a nasty intestinal infection) in hospitalized little old ladies, and possibly issues with calcium absorption.  But: there is also a risk to having uncontrolled reflux: it can cause permanent damage.  Plus, who wants to be miserable with heartburn all the time?

Permanent damage?!

Yes, after chronic exposure to acid, the lining of the esophagus starts to change, and becomes progressively more abnormal.  Eventually, it becomes what we call Barrett’s esophagus, which is considered a pre-cancerous condition, and needs regular monitoring.  Uncontrolled reflux over time can lead to esophageal cancer, and that’s no small thing.

But how do you know it’s REALLY acid reflex… I mean, reflux?

If you’re an otherwise healthy young individual, clinical description is enough for a trial of medication.  If you’re older (my cutoff is 40-45), a doctor might want to do an endoscopy, which a test when they put you to sleep and put a skinny tube with a camera on the end down your throat and into the stomach.  Chances are, after this, they’re still going to put you on a medication trial to see how you do.  The reason to do an endoscopy first is to make sure there is nothing more nefarious, like ulcer, stricture, or worse. (And by that, I mean cancer) If you don’t respond, you might end up getting one of the more esoteric fancy tests.

  • Endoscopy – small skinny tube with camera down throat as above. Requires anesthesia and a ride home usually.
  • pH monitoring – these days this is done with a BRAVO capsule, with is a little acid detecting capsule that we attach to the esophagus, and have you carry around a wireless James Bond type transponder and make a journal of your symptoms and what you’re doing when you get them.  At the end of 48 hours, the capsule will shed and come out in the stool and you need to dig it out and bring it back…..
    JUST KIDDING, no, we don’t want it back, we just want the journal and the transponder thing.
  • Impedance – infrequently, acid reflux doesn’t respond to any medications, and we want to detect whether there NON-acid reflux, like bile.  Impedance testing does that.  Usually, it’s done at a large specialized hospital.  Pretty sure it involves a small tube in the nose for 24 hours, but I don’t perform them, I only order them, and rarely.

I think I can control this with diet, naturally

We all think we can control our body by diet and behavior modification, and that is definitely an important part of it.  Lots of people who are taking PPIs because they want to eat the Doritos would probably be rid of their GERD if they left the Doritos alone.  But sometimes, you do everything right and you STILL get reflux.  And that’s ok, that’s why we’re here.  I have been hearing a lot about apple cider vinegar as a treatment for GERD, and I can’t say that it’s been studied scientifically, but I feel like if you’re a person who’s resistant to medications, the risk of trying this out is low, as is the cost.  It’s a teaspoon of apple cider vinegar in a small glass of water daily.  So, you can definitely try it, and also try caffeine avoidance, small frequent meals, weight loss, give yourself a couple of hours after dinner and before bed, and even put the head of your bed up on a block so gravity can help you.  But if you’re still miserable you might need my help.  And that’s ok.  You’re not a failure.  You just have GERD. ❤

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