GASTRO-ESOPHAGEAL ACID REFLUX DISEASE

WHAT YOU ARE LIKELY TO FEEL

Acid reflux can cause chest discomfort or pain from stomach juice burning your gullet.

The lining of the gullet is not built to withstand acid, and gets inflamed, even ulcerated.

You may have burning discomfort right behind your breastbone, after meals, on bending over or on laying down. Some drinks may hurt on the way down.

When swallowing bits of toast or meat, it may feel as though the food gets stuck on the way down. This last symptom means VISIT DOCTOR.

You may get a mouthful of sour material (stomach juice) even.

A lot of the time however, the acid causes no abnormal feelings as it refluxes. You may just have central chest pain (behind your breastbone,) due to the inflammation or ulceration.

If you suspect this to be the case and you have come to this acid reflux page first, please also look at the

coronary artery disease page and the musculoskeletal chest pain page.

Another possibility is achalasia of the oesophagus, when the food hasn't even got to your stomach before it comes back up again.

GERD ASTHMA AND GERD COUGH

Acid reflux and asthma are both common, and so will coexist frequently just by chance. There is however, more to it than that...

2/3rds of people with asthma have also symptoms of acid reflux, and nearly the same proportion have a hiatal hernia.
The esophageal acid contact time*ˢᵉᵉ ᵇᵉˡᵒʷ is increased in 80% of people with asthma.

Of people with both conditions, more than half have erosions or ulceration in their esophagus.

Acid reflux into our air passages causes quite marked increase in asthma, but it infrequently reaches the throat, let alone tipping into the air passages.
However acid reflux can affect breathing even if only in the lower esophagus (but markedly more the higher it gets.)

If you have bad asthma, or are subject to any sort of attacks waking you from sleep, a test for acid reflux is worth considering. Attending to this problem may help your asthma.

Another intriguing possibility for relating chronic cough to stomach disorders via vitamin B12, has just recently been reported - see reference ⁸ below.

LARYNGEAL REFLUX

Our lower esophagus may dislike acid, but the back of our throat and even more our air passages, dislike it intensely.

Laryngopharyngeal reflux causes quite marked swelling in the throat.

Symptoms include an urge to clear the throat, sore throat, hoarseness, cough, and feeling as if something is stuck in the throat.

TESTS FOR GASTROESOPHAGEAL REFLUX

Endoscopy is commonly used, to see if the lining of your lower esophagus is suffering from acid reflux.

Another test for acid reflux is pH monitoring. You have a tiny probe in your gullet for 24 hours and wear a small recording device.
Episodes of acid reflux show up as drops in pH. The total time with reflux is added up, giving a score*.

This test is also used to determine what dose of proton pump inhibitor drug is needed to ensure the acid is suppressed. If you are considering a trial of one of these drugs because of severe asthma, this may be an important part of the workup.

Another is the acid perfusion test, when 0.1 N hydrochloric acid is trickled into your distal esophagus to determine if your complaints of chest pain originate in the esophagus.
Both acid and a saline control are alternately infused via a nasogastric (NG) tube, without you being aware of the identity of the solution.

TESTING FOR GERD ( GORD ) BY RESPONSE TO TREATMENT

Relief by antacid is a good indication you may have gerd.

Commercial antacid mixtures are not very strong, and you may need even a small glassful. About four antacid tablets can be chewed then swallowed. A heaped teaspoon of baking soda (sodium bicarbonate) in a little warm water is another good way to test this, as long as you do not have severe kidney disease.

You may be offered a drug called a “proton pump inhibitor,” which is actually quite a good option in the short term¹⁴.

This type of drug is more effective than type 2 histamine receptor antagonists such as ranatidine, across all gradesˢᵉᵉ ᵇᵉˡᵒʷ of severity of GORD. Response to one of these drugs, is a good test and good start to treatment. 90% of severe oesophagitis with ulceration, will be healed by 8 weeks of double dose PPI treatment.

ABOUT THE CAUSES OF THIS CONDITION

GERD may be caused by the lower end of the gullet being weak, and/or the stomach being overfull of food plus acid gastric juice.

The last bit of the gullet, just before the stomach, is normally kept tight to prevent reflux. This can be weakened by the body in general being short of the substance Potassium, or when we have a hiatal hernia.

Medications such as diazepam, theophylline, nitrates, and calcium channel blockers may weaken the muscle.

One small study¹¹ found temporomandibular joint dysfunction in a third of people with reflux. It is possible that this may interfere with normal propulsion in the gullet and encourage reflux.


If ones' entire abdominal cavity is overfull with fat (visceral obesity,) there isn't as much room for food in our stomach.
This also encourages reflux.

People at the top end of the weight scale get 50% more episodes of acid up their gullet, as those with healthy weight¹.


It is extremely likely that our gullet's skin varies between individuals, in how well it can tolerate acid or alkali.

This variation is likely also, to be due to a mixture of inherited and environmental factors. The importance of nutrition as one of these, is underlined by the usefulness of Siberian pine nut oil in this condition.


To continue...re. producing too much acid.
Excessive acidity in the stomach is commonly given as the explanation for GERD. This is partly true. The acid is certainly secreted for too long and in too great a volume, but read on...



The normal process...

The upper part of our stomach makes the acid. The lower end (antrum) just before the Duodenum, measures the strength of the acid (the pH.)

When we eat, the stomach pours out digestive juice containing acid and the digestive enzyme “pepsin.”

The food is able to soak up a certain amount of acid, but as acid secretion continues this “buffering capacity” of the food is exceeded, and the pH of the gastric contents drops (more acid - lower pH.)

When the pH drops into the range of 1 to 3, the gastric antrum turns off the acid production and the stomach gets on with digesting our food.


What happens with reflux...

Very commonly, this reflux problem develops because the stomach can’t get the pH sufficiently low for the antrum to “throw the switch” to turn off the acid production.
Not turned off appropriately, the acid production then continues too long and causes havoc, including acid reflux.

This situation is commonly due to deficiency of zinc and/or an infection of the stomach lining with a germ called Helicobactor pylori.
Zinc is part of an enzyme (carbonic anhydrase) in the stomach lining which makes the acid.

Also the gastric antrum switch may malfunction and so be unable to turn the acid off at an appropriate pH.
This may be due to inflammation from bile reflux (duodenogastric reflux, which can also contain pancreatic juice.) Helicobactor infection, toxicity and food intolerance are also possible causes.

Chris Kessler argues for the next development often being carbohydrate malabsorption and bacterial overgrowth.

TESTING FOR THESE CAUSES

Zinc deficiency is a product of modern farming and food processing methods.

Have a look at your finger nails. Are there any white spots?
Do you have bloating or belching after meals?
These are two indications. Night blindness is, and also I think headlights glaring when driving at night.

A taste test is available also. Zinc sulphate has a very bad taste, but our ability to taste and smell may be impaired in zinc deficiency.

Also our body is unlikely to regard something it desperately needs, as distasteful.

For whatever reason, 1 in 1000 zinc sulphate can be used for this purpose. If it doesn't immediately taste bad, you are likely to be deficient.

For more on zinc, see the zinc nutrition pages.



Helicobactor pylori is tested for by blood, breath or fecal tests.

The blood test only tells if you have met the germ. The other two tell if it is alive and well and potentially causing you harm.

TREATMENTS FOR THESE CAUSES

Seafood is the best source of zinc in the diet, but if you have deficiency you need supplements as well.

The oral supplement may be liquid or tablet. Injections of zinc intravenously are by far the most efficient method.

Oral zinc supplements need to be taken away from fiber or soy products, which inhibit the absorption.


Other nutritional supplements may help with the resistance of the skin to acid, and with the repair after acid damage. Siberian pine nut oil has been used, for one.


I always advise people to get rid of Helicobactor pylori infection, as there is some concern about gastric cancer with long term infection. Eradication is sometimes not advised because if nothing else is done, acid reflux can be worsened.


Attending to losing weight if needed.
Lap band surgery has a place even, and can reduce reflux directly as well.


Correcting chronic dehydration is proposed⁷ as a virtual cure-all, for lots of different health problems. I think there is something in this, and am currently (Nov '09) testing it out on myself. Heartburn is one of the many conditions Dr. Batmanghelidj claims to have helped, simply by drinking more water and less caffeine.

This is one of the "5 natural heartburn remedies" in Margie King's excellent article on GreenMedInfo.com


Nissen laparoscopic fundoplication operation, done by an experienced and skilled surgeon, is a major advance in surgical treatment.
It can provide 10 years of drug free treatment.

If nothing else is working and especially if you have a large sliding or para-oesophageal hiatal hernia, this is the next step.

I personally think that surgery is a better option than long term PPI medication, with its attendant risks of vitamin B12 deficiency, fractured hip², pneumonia³-6 and probably heart attack¹⁵. This list is growing all the time.

I'm not so worried if people use PPIs intermittently as needed. The times free of treatment prevent colonization of the stomach by bacteria.

Acid rebound hypersecretion may occur after PPI therapy is ceased¹³. This is partly because it is not treating the cause - like a lot of conventional medicine.

Helicobactor pylori eradication methods.

From acid reflux back to home pain page


More on zinc

Further notes on acid reflux disease

X. Grades of acid reflux oesophagitis - the Los Angeles classification.

If you have been told you have grade A disease, your endoscopist found one or more ulcers no longer than 5mm. and not extending between the tops of two adjacent folds of the skin of the gullet.

Grade B is the same but over 5mm long.

Grade C does extend from one fold to another, but involves less than 3/4 of the circumference of your gullet.

Grade D involves more than 3/4.

The grade is not very important. It doesn't correlate well with symptom severity. The really important reason for endoscopy is seeing whether or not you have Barrett's oesophagus.

This investigation is a good idea if there are changes in long-term symptoms, or dysphagia (difficulty swallowing, especially of bread or meat,) persistent epigastric pain, pain on swallowing, haematemesis (vomiting blood,) anorexia and unexplained weight loss.

One effect of bathing the lower gullet in gastric acid, is change in the skin there. The regular skin is like that on our outside, stratified squamous, with many layers and flattened cells on the surface. It isn't designed to resist acid.

In Barrett's this has changed to columnar epithelium with intestinal metaplasia above the "pinch point" where the oesophagus ends, at the start of the stomach with its folds of "mucosa." This means changed to a single layer of pavers and with mucus producing goblet cells.


This is a precancerous condition, turning cancerous at the rate of 0.5-0.9% per year. Adenocarcinoma of the oesophagus is increasing at a faster rate than any other cancer, world wide. This is probably related to the increase in acid reflux disease.


The worst degree of this condition has dysplasia, where the cells are looking like turning into invasive cancer. This is treated by endoscopic mucosal resection , where the involved skin is removed, to prevent this occurrence.

Radiofrequency ablation (RFA) has been used successfully⁹ to destroy the abnormal tissue, in less severe Barrett's.

Acid reflux in babies and infants

I was once very surprised and relieved by our local paediatrician, when he diagnosed one of my tiny clients as having Sandifer's syndrome.

Little infants sometimes work out for themselves how to minimize or cope with reflux, by putting themselves into very odd postures.

The clue that distinguishes this from nasty brain problems, is that it comes on after feeds.


Babies up to 5 months were studied to see what the best sleeping position was, to minimize reflux¹<span style='font-size: 50%'>.
The surprising result was that sleeping on the left side was better than on the right, and incidentally 30 degrees of head up tilt was ineffective.


One third to one half of babies with reflux have cows milk protein allergy¹², mostly causing their reflux.

Alkaline reflux gastritis and oesophagitis

This relatively uncommon problem can occur after removal of part of the stomach, usually for duodenal ulcer (the duodenal contents ending up refluxing to the gullet.)

Also, in pernicious anaemia, people can suffer from reflux oesophagitis, despite lack of gastric acid.

Duodenal contents are damaging to stomach and gullet.

If you are given this diagnosis, the treatments available in conventional medicine are not particularly pleasant and not particularly effective.

I would try acupuncture, in the hope that it would improve the function of the pyloric sphincter and reduce the duodeno-gastric reflux.

One man's meat is another man's poison - true here too

There are lots of sites cautioning against peppermint, as it can aggravate acid reflux. One of my patients told me their favorite remedy was a few leaves of garden mint steeped in hot water.

Broccoli and cabbage may upset one person, be good for another.

Thee are no general rules.

References for acid reflux page

1. H. B. El-Serag Gut 2008 57: pp. 281-4

2. L. E. Targownik et al CMAJ 2008 179: pp 319-26 There is recent evidence that this association may be from a cause common to osteoporosis and acid reflux, rather than an effect of PPI use.

3. Hauben M et al. Int J Infect Dis 2007;11:417-22.

4. Laheij RJ et al. JAMA 2004;292:1955-60.

5. Sarkar M et al. Ann Intern Med 2008;149:391-8.

6. Gulmez SE et al. Arch Intern Med 2007;167:950-5.

7. Water for Health, for Healing, for Life. You're Not Sick, You're Thirsty! F. Batmanghlidj, M.D. Warner Books

8. The study was presented at the World Allergy Organization XXI World Allergy Congress in Buenos Aires, December 2009, by Giuseppe Guida, MD.

Of 40 patients with chronic unexplained cough, 25 were found to have vitamin B12 deficiency. They were found to have significantly lower threshold values for cough on histamine inhalation challenge, compared to the other 15.

Vitamin B12 supplementation improved histamine thresholds (reduced hyperresponsiveness) in B12 deficient patients without significantly changing them in control subjects.

9. Digestive Disease Week (DDW) 2010: Abstract 358. Presented May 3, 2010

10. Jacinta M Tobin et al Posture and gastro-oesophageal reflux: a case for left lateral positioning Arch Dis Child 1997;76:254-258

11. Gharaibeh TM et al Prevalence of temporomandibular disorders in patients with gastroesophageal reflux disease: a case controlled study. J Oral Maxillofac Surg. 2009. http://www.joms.org/article/S0278-2391(09)01352-4/fulltext

12. http://www.ijponline.net/content/36/1/5/


13. http://www.gastrojournal.org/article/S0016-5085%2809%2900522-8/fulltext

14. Preferably only for 1-2 weeks (see point number two in article...) http://www.gastrojournal.org/article/S0016-5085%2809%2900780-X/fulltext

15. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0124653

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Duodenogastric reflux is passage of intestinal content backwards into the stomach.









































































Intestinal metaplasia means a change towards the (skin) type expected in the stomach and intestine.








EMR is removal of the abnormal (dysplastic) lining at gastroscopy. The scope is used to see where to remove the tissue.




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