What are the oesophagus and stomach
Food passes down the gullet (oesophagus) into the stomach on being eaten. Acid and other chemicals are made by cells in lining of stomach which help in digestion of food. Besides mucus is also made by stomach cells which in turn protects them from damage from the acid.
However the cells lining the oesophagus are different and have little protection from acid.
A circular band of muscle (a sphincter) is found 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. Thus the sphincter acts like a valve in effect.
Understanding oesophagitis and reflux
Oesophagitis refers to the inflammation of the lining of the oesophagus. Reflux of stomach acid which irritates the inside lining of the oesophagus causes most cases of oesophagitis.
Acid reflux means that some acid leaks up(refluxes) into the gullet (oesophagus).A certain amount of acid can be dealt effectively with by the lining of the oesophagus. However, oesophagus is more sensitive to acid in some people and hence develops symptoms with only a small amount of reflux in them. Per contra, some people have a lot of reflux without developing oesophagitis or symptoms.
Gastro-oesophageal reflux disease (GORD)
A general term which describes the range of situations – acid reflux, with or without oesophagitis and symptoms is called gastro – oesophageal reflux disease
Detection of acid reflux and oesophagitis
The main symptom of acid reflux and oesophagitis is Heartburn which is a burning feeling rising from the upper tummy(abdomen) or lower chest up towards the neck. It can be confusing though it has nothing to do with the heart)
The Other common symptoms include pain in the upper abdomen and chest, indigestion (dyspepsia) feeling sick, bloating, an acid taste in the mouth, belching and a burning pain when one swallows hot drinks. Like heartburn, these symptoms tend to come and go, and tend to be worse after a meal.
Some uncommon symptoms: may occur and can make the diagnosis difficult, as these symptoms can mimic other conditions. For example:
(i)Severe chest pain developing in some cases which may be mistaken for a heart attack.
(ii)a persistent cough occurring particularly at night due to the refluxed acid irritating the
(iii)windpipe (trachea). Asthma symptoms of cough and wheeze can sometimes be due to acid leaking up (reflux).
(iv)Sometimes occurring of other mouth and throat symptoms such as gum problems, bad breath, sore throat, hoarseness, and a feeling of a lump in the throat.
Causes and effect of acid reflux
The circular band of muscle (sphincter) at the bottom of the gullet (oesophagus) normally prevents acid leaking up (reflux). Problems occur if the sphincter does not work very well. This is common but in most cases it is not known why it does not work so well.
In some cases the pressure in the stomach rises higher than the sphincter can withstand – for example, during pregnancy, after a large meal, or when bending forward.
If you have a hiatus hernia (a condition where part of the stomach protrudes into the chest through the diaphragm), you have an increased chance of developing reflux.
Most people experience heartburn at some time, perhaps after a large meal. However, about 1 adult in 3 has some heartburn every few days, and nearly 1 adult in 10 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 quality of life. Regular heartburn is more common in smokers, pregnant women, heavy drinkers, those who are overweight, and those aged between 35 and 64 years.
Investigations that might be done
Investigations are not usually necessary if one has typical symptoms. Many people experiencing acid leaking up (refluxing) into the gullet (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, or do not improve with treatment, or are not typical of GORD.
1. Gastroscopy (endoscopy) is the common test in which a thin, flexible telescope is passed down the oesophagus into the stomach. This allows a doctor or nurse to look inside. With inflammation of the lining of the oesophagus (oesophagitis), the lower part of the oesophagus looks red and inflamed. However, even 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:
(i)Oesophagitis. This term is used when the oesophagus can be seen to be inflamed.
(ii)Endoscopy-negative reflux disease. This term is used when someone has typical symptoms of reflux but endoscopy is normal.
1. If the diagnosis is not clear a test to check the acidity inside the oesophagus may be done
2. To rule out other conditions if the symptoms are not typical other tests such as heart tracings, chest X-ray, etc may be done
Measures against development of symptoms
The following measures are commonly advised. However, there has been little research to prove how well these lifestyle changes help to ease reflux:
Some medicines: may worsen the symptoms . 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, nitrates, and calcium-channel blockers such as nifedipine. But this is not a complete (exhaustive) list.
Weight: Being overweight puts extra pressure on the stomach and 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.
Smoking: The chemicals from cigarettes bring the circular band of muscle (sphincter) at the bottom of the gullet (oesophagus) to rest and make acid leaking up (refluxing) more likely. Symptoms may ease if one is a smoker and stops smoking.
Certain foods and drinks: may make reflux worse in some people. It is thought that some foods may bring the sphincter to rest and allow more acid to reflux. It is difficult to ascertain how much foods contribute. Let common sense be one’s guide. If it seems that a food is causing symptoms, then try avoiding it for a while to see if symptoms improve.
Foods and drinks: that have been suspected of making symptoms worse in some people include peppermint, chocolates, spicy food. Tomatoes, hot drinks, coffee & Alcoholic drinks. Avoid large volume food.
|CAFFEEIENE||Coffee, tea, caffinated soda, chocolate, baked goods with chocolate, sweet tea||Lower fat baked goods with no chocolate, plave water, mineral water|
|HIGH FAT FOODS||Fried oily foods, high fat dairy products, meat||Baked foods, steamed foods, low fatdairy products, lean meat|
|HIGH ACID FRUITS & JUICES||Orange, lemon, lime, grapefruit, pineapple, some berry||Banana, apple, melons|
|MINT||Minty gums (Peppermint), minty hard cany||Pretzels, low fat snacks|
|VINEGAR||Vinaigretted & other sour tasting salad dressings||Low fat dressings that are not sour or vinegar based|
|ALCOHOLIC BEVERAGES||Beer, wine, liquor||Water, Non alcholic beverages without caffeine|
|ALCOHOLIC BEVERAGES||Tomato sauces, ketchup||Low fat dips, bland food, foods without sauce|
Bedtime: If symptoms recur most nights, the following may help:
(i)Going to bed with an empty, dry stomach. To do this, nothing should be eaten in the last three hours before bedtime, and nothing should be drunk in the last two hours before bedtime.
(ii)One can try raising the head of the bed by 10-20 cms (for example, with books or bricks under the bed’s legs). This helps gravity to keep acid from refluxing into the oesophagus. If one does this, additional pillows should not be used because this may increase tummy (abdominal) pressure.
Cures for acid reflux and oesophagitis
Alkaline liquids or tablets that reduce the amount of acid are called Antacids A dose usually gives quick relief. There are many brands which one can buy. One can also get some on prescription. Antacids can be used as required’ for mild or infrequent bouts of heartburn.
Medication for Acid-suppression
If one gets symptoms frequently then one needs to see a doctor who will usually prescribe an acid-suppressing medicine. Mainly two group of medications are used to treat – Proton pump inhibitors (PPI) & Histamine receptor blockers (H2 blockers). H2 blockers are less frequently used now because of superiroty of Proton pump inhibitors. H2 blockers include ranitidine, famotidine, cimetidine & Nizatidine. Proton pump inhibitors include omeprazole, lansoprazole, pantaprazole, rabiprazole, esmoprazole & iloprazole.
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 gullet (oesophagus) to clear. After this, all that one may need 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. Without medication, their symptoms return quickly. Long-term treatment with an acid-suppressing medicine is thought to be safe, and side-effects are uncommon. 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 full dose taken each day is needed by some people.
Metaclopramide a gasrokinetic medicine, speeds up the passage of food through the stomach. It is not commonly used but can help in some cases, particularly if one has marked bloating or belching symptoms.
An operation can ‘tighten’ the lower oesophagus to prevent acid leaking up from the stomach. It can be done by ‘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 one to swallow but then tightens to stop acid reflux.
Probable complications from oesophagitis
Scarring and narrowing (stricture). If one has severe and long-standing inflammation it can cause a stricture of the lower gullet (oesophagus) . However this is uncommon.
Barret’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– One’s risk of developing cancer of the oesophagus is slightly increased compared to the normal risk if one has long-term acid reflux.
It needs to be emphasised that most people with reflux do not develop any of these complications. One has to apprise one’s doctor if one has pain or difficulty (food ‘sticking’) when one swallows, which may be the first symptom of a complication.
Acid reflux is the condition when acid from the stomach leaks up into the gullet (oesophagus) causing heartburn and other symptoms. A common treatment which usually works is a medicine which reduces the amount of acid made in the stomach. Some people resort to short courses of medication on appearance of symptoms whereas there are others who need long-term daily medication to keep symptoms at bay.