What is acid reflux?

Acid reflux refers to the flow of stomach juices into the esophagus in a way that creates an irritation on the lining of esophagus. While the periodic presence of the stomach’s liquid contents in the esophagus is normal, the amount of these juices, their acidity, and the frequency with which this reflux takes place can often become excessive.

At the juncture of the stomach and esophagus is a sphincter muscle that closes to prevent too much of the acidic liquid in the stomach from entering the esophagus. Sometimes this reflex for closing off the upward movement of stomach acid functions poorly (and the valve opens at inappropriate times) or the stomach becomes to acidic, or both, resulting in the sensation of burning in the chest or throat.

When the condition is chronic, it often referred to as GERD (Gastroesophageal Reflux Disease). Regular or serious reflux can also affect the throat (pharynx, causing sore throat) and even the voice box (larynx, causing hoarseness). In severe cases it can lead to significant complications, such as inflammation, ulcers, strictures, pre-cancerous tissue changes, cough, or other problems.

If the acid damages the cells on the lining of the esophagus, these cells can become abnormal, causing a condition called Barrett’s esophagus. The cells loose their pink coloration and gradually take on a reddened appearance, as they become, microscopically, more like the cells within the stomach or intestine. Only a minority of people with GERD has the condition long enough and severely enough to develop Barrett’s esophagus. And, of those who do, only small portion (less than one percent) will go on to develop cancer of the esophagus as a result.

 

What are causes and risk factors for acid reflux?

Reflux disease affects tens of millions of people in the U.S. with varying degrees of severity. It is not know for certain why some people are more disposed to high stomach acidity or retrograde flow of peptic juices. A few risk factors are known:

• age. The development of at least mild to severe reflux starting in the 30s, 40s, or 50s is common, in part as the pyloric sphincter valve loses conditioning.

• diet and lifestyle.  Many types of foods and spices, as well eating patterns and habits, can contribute to acid reflux.

• pregnancy. Reflux is more common during pregnancy, presumably due, at least in part, to changes in pressure within the abdomen.

• weakened esophageal muscles. Certain neurological and other conditions can weaken the valve-like function of the top of the stomach and bottom of the esophagus.

• hiatal hernia.

• and smoking. Smoking can increase acidity in the stomach.

 

What are the symptoms of acid reflux?

The primary manifestations of acid reflux are:

• frequent and persistent heartburn (burning sensation in the esophagus or deep in the throat, often after eating);

• backflow of acidic stomach contents or a sensation of regurgitating stomach contents into the esophagus (sometimes leaving a sour or bitter taste in the mouth);

• difficult or painful swallowing;

• change in voice quality;

• and discomfort or poor sleep at night.

Severe GERD can inflame the esophagus (esophagitis) to the point of causing severe chest pain or esophageal bleeding or narrowing.   Uncommonly, GERD can even cause patients to aspirate (breath in) acidic gastric fluids.  These stomach juices pass up the esophagus and are drawn into the wind pipe (trachea), which can lead to chronic inflammation and pneumonia in the lungs.

More on Barrett’s esophagus Experts believe that Barrett’s esophagus results from injury that the cells lining the esophagus suffer when exposed too often to the acidic environment caused by reflux. These squamous cells in the squamous mucosa on the surface of the esophagus become damaged, and a healing process ensues that causes cells in the wall of the esophagus to change function and shape, in a process called metaplasia, producing metaplastic tissue. The cells become more like those in the stomach and thus, in effect, the normal juncture of the esophagus and stomach moves higher in these patients. Some individuals may be predisposed to these types of tissue changes, and individuals with more severe reflux problems are more likely to develop Barrett’s. While acid reflux, of course, produces a specific set of symptoms, Barrett’s itself does not. Therefore, patients with chronic reflux are often screened for Barrett’s by undergoing an upper endoscopy. The gastroenterologist performing this procedure will visually assess the condition of the esophagus through the endoscope, especially in the area where it meets the stomach and will usually take a small scraping of cells to be evaluated in the pathology lab. The team may repeat this procedure if initial samples indicate the possibility of dysplasia. If microscopic evaluation of the esophageal cells confirms Barrett’s, the tissue in the altered area of the esophagus is considered a pre-malignant condition called dysplasia. In a small percentage of patients this type of tissue can gradually become cancerous. Esophageal adenocarcinoma is dangerous type of cancer that can spread to nearby lymph nodes or other parts of the body. Its incidence is on the rise, and middle-aged-to-older white and Hispanic males are at greater risk. For this reason, patients with Barrett’s should undergo periodic endoscopy assessments to monitor the condition. Many specialists believe that successfully treating the symptoms of reflux can help to prevent Barrett’s esophagus or slow its progression. But, if after repeated testing, the cancer specialists conclude that the patient has high-grade dysplasia, they may recommend surgical removal of the patient’s esophagus, because a high percentage of these patients also have or will have invasive esophageal cancer, which is difficult to detect. Other experts recommend repeat endoscopy every three to six months, with surgical removal only if and when cancer can be confirmed. The operation, a major procedure that is difficult to undergo, is only recommended for patients in otherwise sound health. To learn more about surgery for cancer of the esophagus, see Frankford’s Division of Surgical Oncology. A number of new or experimental approaches for preventing or treating Barrett’s are also in use. These include accessing the dysplasic tissue through the esophagus and then using one more methods to remove or destroy this abnormal tissue on the surface of the esophagus.

How is acid reflux diagnosed?

History of the symptoms and observation of their response to noninvasive treatments such as antacid medications are the best indicators of reflux disease. In addition to taking a medical history and performing a physical examination, physicians may request the following diagnostic procedures in order to diagnose ulcers:

• upper endoscopy;

•  24-48 hour measurement of the degree of acidity in the esophagus (via tiny sensing devices placed in the esophagus);

•  esophageal motility testing, gastric emptying studies, or acid perfusion tests;

• or CT scan.

  

How is reflux disease treated?

Treatment for acid reflux falls into three main areas:

• diet and lifestyle.  Patients can identify foods that trigger reflux and can eliminate them from their diets. They may also learn to change other habits, such as eating smaller amounts, avoiding fried and fatty foods, losing weight (to take pressure off the stomach), not eating within three hours of bedtime, elevating the head of their beds, avoiding physical activity after eating, avoiding clothes that fit tightly around the stomach, and stopping smoking. Stress reduction can also play a roll for some patients.

• medications. Over-the-counter and prescription antacids or acid-controlling drugs are the most widely used class of medications in the U.S., other than analgesics. Conventional over-the-counter antacids can be useful for occasional, situational reflux. People who suffer from chronic reflux disease, may use one of the newer or stronger classes of agents available over the counter or by prescription. These drugs, which have proven safe for long-term use, include H2-blockers (to reduce the amount of acid in the stomach by blocking histamine, a powerful stimulant of acid secretion) and proton-pump inhibitors (to more completely block stomach acid production by stopping the stomach's acid pump, the final step of acid secretion).

• surgery.  Surgery to treat reflux disease is also an important option in treatment.