Acid reflux and oesophagitis

What are acid reflux and oesophagitis?

• Acid reflux means that some acid leaks up (refluxes) into the oesophagus.

• Oesophagitis means inflammation of the lining of the oesophagus. Most cases of oesophagitis are due to reflux of stomach acid which irritates the inside lining of the oesophagus.

The lining of the oesophagus can cope with a certain amount of acid. In some people their oesophagus lining is more sensitive than others, so some people will develop symptoms with only a small amount of reflux whilst other people may have higher levels of acid reflux without developing oesophagitis or other symptoms.

Gastro-oesophageal reflux disease (GORD)

This is a general term which describes the range of this condition - acid reflux, with or without oesophagitis or other symptoms.

Symptoms of acid reflux and oesophagitis

• Heartburn: this is the main symptom. This is a burning feeling which rises from the upper tummy (abdomen) or lower chest up towards the neck. (It is a confusing term as it has nothing to do with the heart!)

• Other common symptoms: these include pain in the upper abdomen and chest, feeling sick, an acid taste in the mouth, bloating, belching, indigestion (dyspepsia) and a burning pain when swallowing hot drinks. Like heartburn, these symptoms tend to come and go and are often worse after a meal.

• Some uncommon symptoms: these may occur and if they do, can make the diagnosis difficult, as these symptoms can mimic other conditions. For example:
  

  • A persistent cough, particularly at night, sometimes occurs. This is due to the refluxed acid irritating the windpipe (trachea). Symptoms of cough and wheeze can be due to acid leaking up (reflux) but can sometimes be confused with asthma.

  • Other mouth and throat symptoms sometimes occur, such as gum problems, bad breath, sore throat, hoarseness and a feeling of a lump in the throat.

  • Severe chest pain develops in some cases (and may be mistaken for a heart attack).

What causes acid reflux?

There is a circular band of muscle (sphincter) at the bottom of the oesophagus which normally prevents acid leaking up (reflux). Problems occur if the sphincter is not working as well as it should. This is common but in most cases it is unclear why it does not work as well.

Sometimes the cause is obvious, for example when the pressure in the stomach rises higher than the sphincter can withstand - often during pregnancy, after a large meal, or when bending forward. With a hiatus hernia (a condition where part of the stomach protrudes into the chest through the diaphragm), there is also an increased chance of developing reflux. See the separate leaflet called Hiatus Hernia for more details.

There is a bacteria called helicobacter pylori which commonly lives in the stomach but can cause symptoms very similar to acid reflux and oesophagitis. This can be tested for via a stool test and is often done when people develop new symptoms.

How common is acid reflux?

Most people have heartburn at some time, perhaps after a large meal. However, about one adult in three has some heartburn every few days, and nearly one adult in ten has heartburn at least once a day. In many cases it is mild and soon passes. However, it is quite common for symptoms to be frequent or severe enough to affect someone's quality of life.

Regular heartburn is more common in smokers, pregnant women, people who drink more than the recommended levels of alcohol, those who are overweight and those aged between 35 and 64 years.

How is acid reflux and oesophagitis diagnosed?

Tests are not always necessary if the symptoms are typical. Many people experiencing acid leaking up (refluxing) into the oesophagus are diagnosed with 'presumed acid reflux'. In this situation they have typical symptoms and the symptoms are eased by treatment. Tests may be advised if symptoms are severe, do not improve with treatment or are not typical of GORD.

• Gastroscopy (endoscopy) is the common test. A thin, flexible telescope is passed down the oesophagus into the stomach. This allows a clinician to look inside. With inflammation of the lining of the oesophagus (oesophagitis), the lower part of the oesophagus looks red and inflamed. However, if it looks normal, it does not rule out acid reflux. Some people are very sensitive to small amounts of acid and can have symptoms with little or no inflammation to see. Two terms that are often used after an endoscopy are:
  

  • Oesophagitis. This term is used when the oesophagus can be seen to be inflamed.

  • Endoscopy-negative reflux disease. This term is used when someone has typical symptoms of reflux but endoscopy is normal.

• A test to check the acidity inside the oesophagus may be done if the diagnosis is not clear.

• Other tests such as heart tracings, chest X-ray, etc, may be done to rule out other conditions if the symptoms are not typical.

Treatments for acid reflux and oesophagitis

Antacids

Antacids are alkaline liquids or tablets that reduce the amount of acid. A dose usually gives quick relief. There are many brands which can be bought over the counter or can be prescribed. . Antacids can be used 'as required' for mild or infrequent bouts of heartburn.

Acid-suppressing medicines

Clinical advice should be sought if there are frequent symptoms. An acid-suppressing medicine will usually be advised. Two groups of acid-suppressing medicines are available - proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). They work in different ways but both reduce (suppress) the amount of acid that the stomach makes.

PPIs include omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. H2 blockers include cimetidine, famotidine and nizatidine.

In general, a PPI is used first, as these medicines tend to work better than H2 blockers. A common initial plan is to take a full-dose course of a PPI for a month or so. This often settles symptoms down and allows any inflammation in the oesophagus to clear. After this, all that may be needed is to go back to antacids 'as required' or to take a short course of an acid-suppressing medicine 'as required'.

However, some people need long-term daily acid-suppressing treatment because, without medication, their symptoms return quickly. The aim is to take a full-dose course for a month or so to settle symptoms. After this, it is common to 'step down' the dose to the lowest dose that prevents symptoms. However, the maximum dose taken each day is needed by some people.

Recent research has found a link between long-term treatment with PPIs and gastric cancer, although further studies are needed. H2 blockers may therefore be preferred for long-term use. Some people find that only PPIs control their symptoms. Each individual needs to weigh up the risks and benefits. With some conditions, like Barrett's oesophagus, PPIs may be recommended for longer term protection and to prevent the condition getting worse.

Surgery

An operation can 'tighten' the lower oesophagus to prevent acid leaking up from the stomach. It can be done by laparoscopic or "keyhole" surgery. In general, the success of surgery is no better than acid-suppressing medication. However, surgery may be an option for some people whose quality of life remains significantly affected by their condition and where treatment with medicines is not working well or not wanted long-term.

Another procedure being used involves placing a small magnetic device around the lower oesophagus. The device allows swallowing but then tightens to stop acid reflux. This is not often used in the UK at the moment but there are several centres (mainly in London) offering this procedure.

Lifestyle changes for acid reflux and oesophagitis

The following are commonly advised. There is good evidence that some lifestyles (being overweight, smoking, eating more than needed to feel full) make acid reflux and oesophagitis more likely to occur and that managing these can reduce symptoms.

• Smoking. The chemicals from cigarettes relax the circular band of muscle (sphincter) at the bottom of the gullet (oesophagus) and make acid leaking up (refluxing) more likely. Symptoms may ease if smokers stop smoking.

• Some foods and drinks may make reflux worse in some people. It is thought that some foods may relax the sphincter and allow more acid to reflux. It is difficult to be certain how much foods contribute but if it seems that a food is causing symptoms then it is sensible to try avoiding it for a while to see if symptoms improve. There is no test for this. Foods and drinks that have been suspected of making symptoms worse in some people include peppermint, tomatoes, chocolate, spicy foods, hot drinks, coffee and alcoholic drinks. Also, avoiding large-volume meals may help. Some people find an alkaline diet beneficial. This can be achieved by increasing intake of fibre, vegetables and non-acidic fruits. There is also evidence that eating too quickly or eating more than is needed to feel comfortably full can make acid reflux worse. See the separate leaflet called Oesophageal reflux diet sheet for more details.

• Some medicines may make symptoms worse. They may irritate the oesophagus or relax the sphincter muscle and make acid reflux more likely. The most common culprits are anti-inflammatory painkillers (such as ibuprofen or aspirin). Others include diazepam, theophylline, calcium-channel blockers (such as nifedipine) and nitrates. But this is not a complete (exhaustive) list. It is sensible to seek medical advice if it is suspected that a medicine is causing the symptoms, or making symptoms worse.

• Weight. People who are overweight have extra pressure on their stomach which encourages acid reflux. Losing some weight may ease the symptoms.

• Posture. Lying down or bending forward a lot during the day encourages reflux. Sitting hunched or wearing tight belts may put extra pressure on the stomach, which may make any reflux worse.

• Bedtime. If symptoms recur most nights, the following may help:
  

  • Going to bed with an empty, dry stomach - not eating in the last three hours before bedtime and not drinking in the last two hours before bedtime.

  • Trying to raise the head of the bed by 10-20 cm (for example, with books or bricks under the bed's legs). This helps gravity to keep acid from refluxing into the oesophagus. It is best not to use additional pillows as this may increase abdominal pressure overnight.

Complications from oesophagitis

• Scarring and narrowing (stricture). If there is severe and long-standing inflammation due to the acid reflux and oesophagitis, it can cause a stricture of the lower oesophagus. This is uncommon.

• Barrett's oesophagus. In this condition the cells that line the lower oesophagus become changed. The changed cells are more prone than usual to becoming cancerous. (About 1 or 2 people in 100 with Barrett's oesophagus develop cancer of the oesophagus.)

• Cancer. The risk of developing cancer of the oesophagus is slightly increased compared to the normal risk with long-term acid reflux.

Most people with reflux do not develop any of these complications. It is important to seek medical attention if there is pain or difficulty (food 'sticking') on swallowing which may be the first symptom of a complication.

Understanding the oesophagus and stomach

When eating, food passes down the oesophagus into the stomach. Cells in the lining of the stomach make acid and other chemicals which help to digest the food. Stomach cells also make mucus which protects them from damage from the acid. The cells lining the oesophagus are different and have little protection from acid.

There is a circular band of muscle (a sphincter) at the junction between the oesophagus and stomach. This relaxes to allow food down but then normally tightens up and stops food and acid leaking up (refluxing) into the oesophagus. In effect, the sphincter acts like a valve.

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