Acid reflux is a very common condition. It is characterized by a burning pain, known as heartburn, felt internally around the lower chest area. It is caused by stomach acid flowing back up into the food pipe.
Gastroesophageal reflux disease (GERD) is diagnosed when acid reflux occurs more than twice a week.
This page explains what causes acid reflux and gastroesophageal reflux disease. We also cover symptoms, how the condition is diagnosed, treatment options available for the management of the condition, and how lifestyle measures can help.
Contents of this article:
Here are some key points about acid reflux. More detail and supporting information is in the main article.
- Acid reflux is also known as heartburn, acid indigestion, or pyrosis
- It happens when some of the acidic stomach contents go back up into the esophagus
- Acid reflux creates a burning pain in the lower chest area, often after eating
- Lifestyle risk factors include obesity and smoking
- Drug treatments are the most common therapy and are available on prescription and OTC
What is acid reflux?
Diagram of the digestive system.
Acid reflux is when some of the acid content of the stomach flows up into the esophagus - into the gullet, which moves food down from the mouth. Despite the name, heartburn has nothing to do with the heart.
The stomach contains a strong acid - hydrochloric acid - to help break down food and protect against pathogens such as bacteria.
The lining of the stomach is specially adapted to protect it from the powerful acid, but the esophagus is not protected.
A ring of muscle - the gastroesophageal sphincter - normally acts as a valve that lets food into the stomach but not back up into the esophagus. When this valve fails, and stomach contents are regurgitated into the esophagus, the symptoms of acid reflux are felt, such as heartburn.
Exact figures vary but acid reflux is considered very common, and diseases resulting from acid reflux are the most common gut complaint seen by United States hospital departments.
The American College of Gastroenterology says that over 60 million Americans experience heartburn at least once a month, and at least 15 million as often as daily.
Gastroesophageal reflux disease has the highest rates in Western countries, affecting an estimated 20-30 percent of the population.
Although acid reflux is common and not dangerous, chronic heartburn can lead to serious complications.
Causes of acid reflux
We all may experience acid reflux occasionally, often associated with certain food and drink. Recurrent acid reflux that leads to disease has other causes and risk factors and is termed gastroesophageal reflux disease (GERD).
Gastroesophageal reflux disease is seen in people of all ages, sometimes for unknown reasons (idiopathic). Often, the cause is attributable to a lifestyle factor, but it can also be due to causes that cannot always be prevented.
One such cause of GERD is a hiatal (or hiatus) hernia. This is an anatomical abnormality where a hole in the diaphragm allows the upper part of the stomach to enter the chest cavity, sometimes leading to GERD. Pregnancy can also cause acid reflux due to extra pressure being placed on the internal organs.
Other risk factors are more easily controlled:
- Smoking (active or passive)
- High intake of table salt
- Low dietary fiber intake
- Low levels of physical exercise
- Medications, including drugs for asthma, calcium-channel blockers, antihistamines, painkillers, sedatives, and antidepressants
- Alcohol or caffeine intake
Symptoms of acid reflux
Acid reflux, whether it is a harmless, isolated episode of the sort we all experience at some point, or the persistent problem of gastroesophageal reflux disease, usually produces the same main symptom: Heartburn.
Heartburn is a discomfort - happening in the esophagus and felt behind the breastbone area - that takes the form of a burning sensation; it generally gets worse when the person lies down or bends over. It can last for several hours and also tends to worsen after eating food.
The pain of heartburn may move up toward the neck and throat; stomach fluid can reach the back of the throat in some cases, producing a bitter or sour taste.
If heartburn occurs regularly - two or more times a week - it is termed gastroesophageal reflux disease, or GERD for short. GERD can also have other symptoms, including:
- Dry, persistent cough
- Asthma and recurrent pneumonia
- Throat problems - soreness, hoarseness, or laryngitis (voice box inflammation)
- Difficulty or pain when swallowing
- Chest or upper abdominal pain
- Dental erosion
- Bad breath
Tests and diagnosis
Acid reflux and heartburn are common and relatively easy to diagnose, however, they can be confused with other chest complaints such as:
- Heart attack
- Chest wall pain
- Pulmonary embolus
Gastroesophageal reflux disease is often diagnosed simply by finding no improvement in heartburn symptoms in response to lifestyle changes and acid reflux medication.
Gastroenterologists may also arrange the following investigations:
- Endoscopy - camera imaging
- Biopsy - taking a tissue sample for laboratory analysis
- Barium X-ray - imaging the esophagus, stomach, and upper duodenum after swallowing a chalky liquid that helps provide contrast on images
- Esophageal manometry - pressure measurement of the esophagus
- Impedance monitoring - measuring rate of fluid movement along the esophagus
- pH monitoring - acidity testing
Treatment and prevention of acid reflux
Zantac is one medication for heartburn relief.
In this section we will first list the potential treatments for acid reflux and heartburn, then go on to explain how they work:
- Proton-pump inhibitors - including omeprazole, rabeprazole, and esomeprazole
- H2 blockers - including cimetidine, ranitidine, and famotidine
- OTC treatments - antacids
- Alginate drugs - including Gaviscon
Proton-pump inhibitors and H2 blockers decrease acid production and thereby reduce the potential for damage caused by acid reflux.
These medications are generally safe and effective, but like any prescription drug, they are not appropriate for all people with reflux disease and can cause side effects.
For instance, they can cause problems absorbing nutrients, which can lead to malnutrition.
OTC remedies for acid reflux
For people who experience heartburn or indigestion infrequently, perhaps in association with occasional food and drink triggers, OTC treatments to reduce the acidity of the stomach contents are available.
These liquid and tablet formulations are called antacids, and there are dozens of brands available, all with similar effectiveness. They may not work for everyone, and any need for regular use should be discussed with a doctor.
Antacids provide rapid but short-term relief by reducing the acidity of the stomach contents.
Alginate drugs such as Gaviscon
Gaviscon is a well-known over-the-counter heartburn medication.
Gaviscon is probably the best-known heartburn therapy. It has a different mode of action than antacid drugs. Alginate drugs such as Gaviscon vary slightly in composition, but they usually contain an antacid.
The alginic acid works by creating a mechanical barrier against the stomach acid, forming a foamy gel that sits at the top of the gastric pool itself.
Any reflux is then relatively harmless as it consists of alginic acid and not damaging stomach acid.
The active ingredient - alginate - is found naturally in brown algae.
Although the main options for the management of GERD have been covered above, there are others, including:
- Sucralfate acid suppressants
- Potassium-competitive acid blockers
- Transient lower esophageal sphincter relaxation (TLESR) reducers
- GABA(B) receptor agonist
- mGluR5 antagonist
- Prokinetic agents
- Pain modulators
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors (SSRIs)
- Theophylline - serotonin-norepinephrine reuptake inhibitor
In rare cases, gastroesophageal reflux disease that is severe and unresponsive to medical treatment may warrant surgical intervention in the form of a procedure called fundoplication.
Prevention of acid reflux through lifestyle control
Losing weight and stopping smoking will remove two lifestyle risk factors associated with acid reflux.
Lifestyle can play a large part in the development of acid reflux-related problems, and changes to lifestyle or behavior can prevent or improve symptoms.
The American Gastroenterological Association offers the following list of things that might help resolve symptoms:
- Avoid food, drinks, and medicines that you find to be associated with heartburn irritation
- Eat smaller meals
- Improve posture - for instance, siting up straighter
- Wear loose clothing
- Do not lie down for 2-3 hours after a meal
- Lose weight if overweight or obese
- Avoid increased pressure on your abdomen, such as from tight belts or doing sit-up exercises
- Stop smoking
- Reduce intake of chocolate, carbonated drinks, and acidic juices
Risks from long-term GERD
It is important to address persistent problems with gastroesophageal reflux disease as long-term untreated acid reflux can lead to serious complications, including an increased risk of cancer.
Long-term, continual exposure to stomach acid can damage the esophagus, leading to:
- Esophagitis - the lining of the esophagus is inflamed, causing irritation, bleeding, and ulceration in some cases
- Strictures - damage caused by stomach acid leads to scar development and difficulties swallowing, with food getting stuck as it travels down the esophagus
- Barrett's esophagus - a serious complication where repeated exposure to stomach acid causes changes in the cells and tissues lining the esophagus with potential to develop into cancer cells
Both esophagitis and Barrett's esophagus are associated with a higher risk of cancer.
There was a landmark study published in the New England Journal of Medicine in 1999 that found a link between untreated acid reflux and cancer. Its conclusion reads as a stark warning against leaving acid reflux untreated for a long time:
"There is a strong and probably causal relation between gastroesophageal reflux and esophageal adenocarcinoma."