Acid Reflux (GORD)

What is acid reflux?

It is normal for the stomach to produce acid, and the lining of the stomach has adapted in such a fashion that it is able to resist damage from acid being present. Therefore, as long as acid remains in the stomach, it does not lead to any problems or symptoms.

 

Acid reflux refers to the phenomenon where stomach acid rises up into the oesophagus (the long food pipe that transports food from the throat to the stomach). The lining of the oesophagus has not adapted to withstand such acidity, and is therefore susceptible to the harmful effects of stomach acid. This can lead to inflammation in the oesophagus, and give rise to the typical symptoms of acid reflux.

 

Is acid reflux the same as GORD or GERD?

Some degree of acid reflux is normal. Many healthy people experience acid reflux from time to time. In fact, studies using 24-hour pH measurements in healthy people with no symptoms of reflux show that in such people, acid reflux into the oesophagus can still be occurring for up to 5% of the day. 

 

Therefore, gastro-oesophageal reflux disease (abbreviated to GORD) is considered present when acid reflux occurs in a patient often enough and to a sufficient severity where it leads to troublesome symptoms or complications. However for simplicity, the terms acid reflux and GORD will be used interchangeably hereafter in this guide.

 

What is the difference between heartburn and reflux/GORD?

Heartburn (unpleasant burning felt behind the breastbone) is the most characteristic symptoms of gastro-oesophageal reflux disease. However, there are several other symptoms of GORD (see below).

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What are the symptoms of acid reflux?

The two most typical symptoms of acid reflux are:

• Heartburn, an uncomfortable burning sensation in the chest (behind the breastbone) 

• Regurgitation, a sensation of fluid moving up the chest, throat +/- into the mouth, often accompanied by a sour taste in the mouth

 

There are other symptoms that have been associated with reflux, listed below. However, there are numerous causes for these symptoms other than acid reflux, and a careful evaluation is required to determine whether GORD is truly the cause:

• Pain in the chest or upper abdomen

• Cough

• Sore throat and/or voice hoarseness

• Erosion of tooth enamel

• Dysphagia, or difficulty swallowing. Mild difficulty or heightened sensation of food travelling down in the oesophagus is common in GORD. However, this is generally not the primary symptom of acid reflux. If swallowing difficulties are the predominant problem, then other conditions need to first be considered and excluded e.g. EoE, achalasia.

 

How common is acid reflux (GORD)?

GORD is a very common condition, and is one of the most common reasons for people to see a doctor in Western countries. In Australia, GORD is estimated to affect 10-15% of the population. This means that in Australia there are over 3,000,000 people with gastro-oesophageal reflux disease.

 

What causes acid reflux?

The lower oesophageal sphincter (LOS) is a special circular muscle at the bottom of the oesophagus, where it joins the stomach. This muscle should stay closed most of the time to prevent stomach acid rising up into the oesophagus, and opens up to let swallowed food and drink pass into the stomach. If the LOS is abnormally weak, disrupted or anatomically abnormal, then acid reflux is more likely to occur.

 

Some risk factors that may predispose to developing acid reflux include:

• Being overweight or obese: This is one of the strongest risk factors for GORD. Every kilogram extra in weight increases a person’s risk of having GORD. However, the flip side is that every kilogram lost can help improve the symptoms of acid reflux. Excess body weight (especially belly fat) contributes to acid reflux developing by increasing the pressure on and within the stomach; this increases the likelihood of acid being pushed up into the oesophagus.

• Pregnancy: Acid reflux is very common, affecting up to 50% of all pregnant women. Acid reflux tends to worsen as the pregnancy progresses, because of the increasing pressure being placed on the stomach by the enlarging womb.

• Cigarette smoking: Smokers have a weaker lower oesophageal sphincter (LOS) and therefore the barrier to acid reflux occurring is diminished

• Hiatus hernia: A common condition where a small portion of the stomach slides up from the abdominal cavity into the chest cavity, through a muscle called the diaphragm. Many patients with hiatus hernia have no symptoms. However, the presence of a hiatus hernia predisposes a person to developing GORD, by weakening the barrier to reflux at the LOS. A hiatus hernia cannot be seen on the outside of the body, but may be detected by tests such as endoscopy, barium swallow or CT scan.

 

Is there anything I can do to get rid of acid reflux?

Yes – there are several adjustments you can make to your diet and lifestyle which may be all that is necessary to control mild acid reflux. You can try these at home before even seeing a doctor. Even for more severe cases, you should still try these measures as they may help reduce the frequency and severity of symptoms. Try to:

• Change the way that you eat and drink: 'Grazing' on smaller amounts of food more frequently is better for GORD than eating three large meals (as acid reflux is more prone to occur with a full stomach). 

• Change what you eat and drink: There is no strict dietary recommendation for GORD. However, if you find that certain food or drinks aggravate your symptoms, then it is logical to avoid them. Common culprits include coffee, chocolate, tea, alcohol, fizzy drinks, and peppermint. Most of these promote acid reflux by weakening the LOS. A diet high in refined sugars may be implicated. Some patients find fatty and spicy foods aggravate their acid reflux.

• Avoid tight-fitting clothing and belts: These can increase the pressure on the stomach and make it more likely for acid to rise up into the oesophagus.

• Stop smoking: This should be a ‘no-brainer’ – not only will it help with GORD, but it is good for your general health anyway.

• Lose weight if your BMI is above the healthy range: Can be difficult to do, but every kilogram lost reduces the pressure on your stomach, and makes it less likely for acid reflux to occur.

• Elevate the head of the bed: While sleeping, acid reflux can be more likely to occur because the acid no longer has to travel against gravity to reach the oesophagus. Raising the head of the bed can therefore reduce acid reflux at night. You can achieve this either by using a foam wedge pillow (can be purchased from the chemist) or by placing some blocks or thick books under the bedposts .

• Don’t eat for 3 hours before bedtime: Going to bed with an empty stomach reduces the risk of night-time acid reflux. Stay sitting upright or standing for 3 hours after every meal.

 

Can acid reflux be controlled by medications?

If the measures outlined above are not sufficient to control your symptoms, then yes, there are several groups of medications that can be used to help your symptoms:

• Antacids: Simple treatments (e.g. Mylanta, Gaviscon, Rennie) which work by neutralising stomach acid. They are very safe, can be taken as required for an attack of acid reflux, and can be used long-term if effective. 

• Antacid & Alginate combination: Gaviscon Dual Action liquid contains a combination of an antacid along with an alginate which forms a buffer layer on top of stomach acid after meals. Gaviscon Dual Action taken 5 minutes after a meal to help reduce the symptoms of acid reflux occurring after eating.

• Histamine-2 Receptor Antagonists (H2RAs): The only medication of this class currently available in Australia is Tazac (Nizatidine); raniditide/Zantac was removed from the market in 2019. Tazac works by reducing stomach acid production. Nowadays, it is less used in favour of PPIs (see below).

• Proton pump inhibitors (PPIs):  This group includes medications such as pantoprazole, omeprazole, esomeprazole and rabeprazole (you may know them by brand names such as Somac, Losec, Nexium, Pariet and others). These are the most effective medications for treating acid reflux. PPIs work by reducing stomach acidity. They should generally be used at the lowest dose required to control your symptoms (taking on-demand is often OK if that is all you need). In some patients they need to be used long-term, and if this is required it is safe to do so. PPIs are most effective at relieving heartburn but can be less effective in relieving other symptoms associated with acid reflux such as regurgitation, cough, hoarseness and sore throat. These medications work best when taken first thing in the morning, on an empty stomach, at least 30 minutes before breakfast.

 

What are the options if medications don’t help?

If your symptoms are not responding to changes to your lifestyle, diet and medications, then it is important to see a gastroenterologist for further evaluation of your symptoms. This is firstly to ensure that the diagnosis of GORD is correct, and to exclude other conditions which may mimic acid reflux (e.g. eosinophilic oesophagitis, achalasia and cancer of the oesophagus). If GORD is confirmed to be the correct diagnosis, then the severity needs to be determined and your medications may need adjustment.

 

Some of the tests a specialist gastroenterologist may perform for you include:

• Endoscopy: May find inflammation related to acid reflux, pre-cancerous changes related to acid reflux (Barrett’s oesophagus), alternative explanations for the symptoms, or structural abnormalities such as hiatus hernia. However, most patients with acid reflux have a normal endoscopy.

• Oesophageal manometry: Measures the motility, or muscle function, of the oesophagus.

• 24-hour pH study: A thin probe is placed into the oesophagus to measure acid levels over a 24-hour period. This accurately determines the severity of acid reflux.

• Barium swallow: Often performed in patients with acid reflux, but this test is not accurate in diagnosing GORD. May have a role for patients being considered for anti-reflux surgery.

 

When is surgery necessary for acid reflux (GORD)?

The vast majority of people with acid reflux do not need surgery. However, in selected patients with significant symptoms impacting their quality of life, anti-reflux surgery can be a very helpful and effective treatment. However, the decision to undertake surgery for acid reflux is not one taken lightly, as there are risks and potential side effects to consider. These include severe difficulty in swallowing, gas retention in the stomach (bloating), poor stomach emptying (gastroparesis), and general complications that may be associated with any abdominal surgery e.g. hernia, bleeding and perforation.

 

Therefore, before consideration of anti-reflux surgery, patients should be seen by a specialist gastroenterologist with expertise in interpretation of oesophageal investigations. This is to (i) ensure that the diagnosis of GORD is correct, (ii) provide an objective assessment of the severity of GORD through the use of specialised oesophageal testing, and (iii) advise you on the likelihood of you achieving symptom improvement from surgery – a specialist can predict the likelihood of surgery being successful for you based on your symptom profile and test results. In some patients, surgery can leave them worse off and it is important that such patients are not referred for surgery.

 

Who do I see for management of my acid reflux in Sydney?

Acid reflux is a very common problem in the community, and it is appropriate for patients to initially trial some of the simple measures outlined in this article themselves. However, when symptoms do not respond to these measures, it is important to have them evaluated by a specialist gastroenterologist to confirm the diagnosis and provide treatment options. Call A/Professor Santosh Sanagapalli, specialist in oesophageal disorders, if you are being troubled with acid reflux symptoms, for a comprehensive assessment and personalised treatment plan.