Acid Reflux
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Gastroesophageal reflux disease, or Acid Reflux, occurs when the lower
esophageal sphincter (LES) does not close properly and stomach
contents leak back, or reflux, into the esophagus. The LES is a ring
of muscle at the bottom of the esophagus that acts like a valve
between the esophagus and stomach. The esophagus carries food from
the mouth to the stomach.
When refluxed stomach acid touches the lining of the esophagus,
it causes a burning sensation in the chest or throat called
heartburn. The fluid may even be tasted in the back of the mouth,
and this is called acid indigestion. Occasional heartburn is common
but does not necessarily mean one has Acid Reflux. Heartburn that occurs
more than twice a week may be considered Acid Reflux, and it can eventually
lead to more serious health problems.
Anyone, including infants, children, and pregnant women, can have
Acid Reflux.
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The main symptoms are persistent heartburn and acid
regurgitation. Some people have Acid Reflux without heartburn. Instead,
they experience pain in the chest, hoarseness in the morning, or
trouble swallowing. You may feel like you have food stuck in your
throat or like you are choking or your throat is tight. Acid Reflux can
also cause a dry cough and bad breath.
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Studies* show that Acid Reflux is common and may be overlooked in
infants and children. It can cause repeated vomiting, coughing, and
other respiratory problems. Children's immature digestive systems
are usually to blame, and most infants grow out of Acid Reflux by the time
they are 1 year old. Still, you should talk to your child's doctor
if the problem occurs regularly and causes discomfort. Your doctor
may recommend simple strategies for avoiding reflux, like burping
the infant several times during feeding or keeping the infant in an
upright position for 30 minutes after feeding. If your child is
older, the doctor may recommend avoiding
- sodas that contain caffeine
- chocolate and peppermint
- spicy foods like pizza
- acidic foods like oranges and tomatoes
- fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. The doctor
may recommend that the child sleep with head raised. If these
changes do not work, the doctor may prescribe medicine for your
child. In rare cases, a child may need surgery.
*Jung AD. Gastroesophageal reflux in infants and
children. American Family Physician.
2001;64(11):1853-1860.
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No one knows why people get Acid Reflux. A hiatal hernia may contribute.
A hiatal hernia occurs when the upper part of the stomach is above
the diaphragm, the muscle wall that separates the stomach from the
chest. The diaphragm helps the LES keep acid from coming up into the
esophagus. When a hiatal hernia is present, it is easier for the
acid to come up. In this way, a hiatal hernia can cause reflux. A
hiatal hernia can happen in people of any age; many otherwise
healthy people over 50 have a small one.
Other factors that may contribute to Acid Reflux include
- alcohol use
- overweight
- pregnancy
- smoking
Also, certain foods can be associated with reflux events,
including
- citrus fruits
- chocolate
- drinks with caffeine
- fatty and fried foods
- garlic and onions
- mint flavorings
- spicy foods
- tomato-based foods, like spaghetti sauce, chili, and pizza
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If you have had heartburn or any of the other symptoms for a
while, you should see your doctor. You may want to visit an
internist, a doctor who specializes in internal medicine, or a
gastroenterologist, a doctor who treats diseases of the stomach and
intestines. Depending on how severe your Acid Reflux is, treatment may
involve one or more of the following lifestyle changes and
medications or surgery.
- If you smoke, stop.
- Do not drink alcohol.
- Lose weight if needed.
- Eat small meals.
- Wear loose-fitting clothes.
- Avoid lying down for 3 hours after a meal.
- Raise the head of your bed 6 to 8 inches by putting blocks of
wood under the bedposts--just using extra pillows will not help.
Your doctor may recommend over-the-counter antacids, which you
can buy without a prescription, or medications that stop acid
production or help the muscles that empty your stomach.
Antacids, such as Alka-Seltzer, Maalox, Mylanta,
Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs
recommended to relieve heartburn and other mild Acid Reflux symptoms. Many
brands on the market use different combinations of three basic
salts--magnesium, calcium, and aluminum--with hydroxide or
bicarbonate ions to neutralize the acid in your stomach. Antacids,
however, have side effects. Magnesium salt can lead to diarrhea, and
aluminum salts can cause constipation. Aluminum and magnesium salts
are often combined in a single product to balance these effects.
Calcium carbonate antacids, such as Tums, Titralac, and Alka-2,
can also be a supplemental source of calcium. They can cause
constipation as well.
Foaming agents, such as Gaviscon, work by covering your
stomach contents with foam to prevent reflux. These drugs may help
those who have no damage to the esophagus.
H2 blockers, such as cimetidine
(Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and
ranitidine (Zantac 75), impede acid production. They are available
in prescription strength and over the counter. These drugs provide
short-term relief, but over-the-counter H2
blockers should not be used for more than a few weeks at a time.
They are effective for about half of those who have Acid Reflux symptoms.
Many people benefit from taking H2 blockers
at bedtime in combination with a proton pump inhibitor.
Proton pump inhibitors include omeprazole (Prilosec),
lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole
(Aciphex), and esomeprazole (Nexium), which are all available by
prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost
everyone who has Acid Reflux.
Another group of drugs, prokinetics, helps strengthen the
sphincter and makes the stomach empty faster. This group includes
bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide
also improves muscle action in the digestive tract, but these drugs
have frequent side effects that limit their usefulness.
Because drugs work in different ways, combinations of drugs may
help control symptoms. People who get heartburn after eating may
take both antacids and H2 blockers. The
antacids work first to neutralize the acid in the stomach, while the
H2 blockers act on acid production. By the
time the antacid stops working, the H2
blocker will have stopped acid production. Your doctor is the best
source of information on how to use medications for Acid Reflux.
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If your heartburn does not improve with lifestyle changes or
drugs, you may need additional tests.
- A barium swallow radiograph uses x rays to help spot abnormalities
such as a hiatal hernia and severe inflammation of the esophagus. With this
test, you drink a solution and then x rays are taken. Mild irritation will
not appear on this test, although narrowing of the esophagus--called stricture--ulcers,
hiatal hernia, and other problems will.
- Upper endoscopy is more accurate than a barium swallow radiograph
and may be performed in a hospital or a doctor's office. The doctor will
spray your throat to numb it and slide down a thin, flexible plastic tube
called an endoscope. A tiny camera in the endoscope allows the doctor to
see the surface of the esophagus and to search for abnormalities. If you
have had moderate to severe symptoms and this procedure reveals injury to
the esophagus, usually no other tests are needed to confirm Acid Reflux.
The doctor may use tiny tweezers (forceps) in the endoscope to remove a
small piece of tissue for biopsy. A biopsy viewed under a microscope can
reveal damage caused by acid reflux and rule out other problems if no infecting
organisms or abnormal growths are found.
- In an ambulatory pH monitoring examination, the doctor puts a tiny
tube into the esophagus that will stay there for 24 hours. While you go
about your normal activities, it measures when and how much acid comes up
into your esophagus. This test is useful in people with Acid Reflux symptoms
but no esophageal damage. The procedure is also helpful in detecting whether
respiratory symptoms, including wheezing and coughing, are triggered by
reflux.
Surgery is an option when medicine and lifestyle changes do not
work. Surgery may also be a reasonable alternative to a lifetime of
drugs and discomfort.
Fundoplication, usually a specific variation called Nissen
fundoplication, is the standard surgical treatment for Acid Reflux. The
upper part of the stomach is wrapped around the LES to strengthen
the sphincter and prevent acid reflux and to repair a hiatal hernia.
This fundoplication procedure may be done using a
laparoscope and requires only tiny incisions in the abdomen.
To perform the fundoplication, surgeons use small instruments that
hold a tiny camera. Laparoscopic fundoplication has been used safely
and effectively in people of all ages, even babies. When performed
by experienced surgeons, the procedure is reported to be as good as
standard fundoplication. Furthermore, people can leave the hospital
in 1 to 3 days and return to work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two
endoscopic devices to treat chronic heartburn. The Bard EndoCinch
system puts stitches in the LES to create little pleats that help
strengthen the muscle. The Stretta system uses electrodes to create
tiny cuts on the LES. When the cuts heal, the scar tissue helps
toughen the muscle. The long-term effects of these two procedures
are unknown.
Recently the FDA approved an implant that may help people with
Acid Reflux who wish to avoid surgery. Enteryx is a solution that becomes
spongy and reinforces the LES to keep stomach acid from flowing into
the esophagus. It is injected during endoscopy. The implant is
approved for people who have Acid Reflux and who require and respond to
proton pump inhibitors. The long-term effects of the implant are
unknown.
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Sometimes Acid Reflux can cause serious complications. Inflammation of
the esophagus from stomach acid causes bleeding or ulcers. In
addition, scars from tissue damage can narrow the esophagus and make
swallowing difficult. Some people develop Barrett's esophagus, where
cells in the esophageal lining take on an abnormal shape and color,
which over time can lead to cancer.
Also, studies have shown that asthma, chronic cough, and
pulmonary fibrosis may be aggravated or even caused by Acid Reflux.
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- Heartburn, also called acid indigestion, is the most common symptom of
Acid Reflux. Anyone experiencing heartburn twice a week or more may have
Acid Reflux.
- You can have Acid Reflux without having heartburn. Your symptoms could
be excessive clearing of the throat, problems swallowing, the feeling that
food is stuck in your throat, burning in the mouth, or pain in the chest.
- In infants and children, Acid Reflux may cause repeated vomiting, coughing,
and other respiratory problems. Most babies grow out of Acid Reflux by their
first birthday.
- If you have been using antacids for more than 2 weeks, it is time to see
a doctor. Most doctors can treat Acid Reflux. Or you may want to visit an
internist--a doctor who specializes in internal medicine--or a gastroenterologist--a
doctor who treats diseases of the stomach and intestines.
- Doctors usually recommend lifestyle and dietary changes to relieve heartburn.
Many people with Acid Reflux also need medication. Surgery may be an option.
No one knows why some people who have heartburn develop Acid Reflux.
Several factors may be involved, and research is under way on many
levels. Risk factors--what makes some people get Acid Reflux but not
others--are being explored, as is Acid Reflux's role in other conditions
such as asthma and bronchitis.
The role of hiatal hernia in Acid Reflux continues to be debated and
explored. It is a complex topic because some people have a hiatal
hernia without having reflux, while others have reflux without
having a hernia.
Much research is needed into the role of the bacterium
Helicobacter pylori. Our ability to eliminate H.
pylori has been responsible for reduced rates of peptic ulcer
disease and some gastric cancers. At the same time, Acid Reflux, Barrett's
esophagus, and cancers of the esophagus have increased. Researchers
wonder whether having H. pylori helps prevent Acid Reflux and other
diseases. Future treatment will be greatly affected by the results
of this research.
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