Acid Reflux: Assessment and Treatment
Updated: Nov 8
Part 1: What is Acid Reflux?
If there is one common ailment among most adults, it is acid reflux. Uncomfortable, burning sensation in your chest after a delicious, satisfying meal or in the middle of the night? Chances are, stomach acid is backing up into the delicate tissue of your esophagus. Acid reflux can be occasional, but when it persists more than two times a week, you likely have gastroesophageal reflux disease (GERD). What seems easily remedied by medication, may also lead to severe health conditions.
TOP causes of Acid Reflux:
1. My LES won’t stay closed.
The esophagus is the tube that connects your throat to your stomach. At the connection of the lower esophagus and your stomach is a muscle ring that you really want to remain closed after your food and drink passes. The lower esophageal sphincter (LES), when properly closed, prevents stomach acid and contents from going back up. You can’t voluntarily control your LES, so what’s wrong with it? Doctors speculate that excess pressure on the LES from things like frequent large meals and obesity can cause it to have a weak contraction or not completely close.
2. Hiatal hernia.
Now picture the diaphragm, a large sheet of muscle that separates the thoracic cavity (heart and lungs) from the abdominal cavity. The diaphragm is important in expanding the thoracic cavity when we breathe. Therefore, when part of the stomach bulges its way into the thoracic cavity, we are bound to have problems.
A hiatal hernia causes disruptions in the location and angle of the LES. The LES and diaphragm are normally at the same level and work together to prevent reflux. When a hernia pushes part of the stomach up, the LES is also pushed up. This causes 2 problems. One, having the LES and diaphragm at different levels decreases the pressure of the LES. So, when the LES relaxes with each swallow, the stomach acid in the hernial sac is easily refluxed. Two, having the LES pushed up affects the angle and valve-like function of the tissue that normally prevents reflux.
Cigarettes contain nicotine. Nicotine relaxes smooth muscles. The lower esophageal sphincter is a smooth muscle. It takes about six hours from the last cigarette you smoke for the effect on the esophagus to wear off. Smoking also damages the mucus membranes of the esophagus, which are meant to protect the esophagus from any damage. And, smoking also makes your stomach produce more acid.
Acid reflux is most common after meals. It is always best to remain vertical to allow gravity to help keep acid in your stomach. Try not to eat large meals in one sitting, and try not to eat just before bedtime.
Part 2: Assessment and Treatment
There are three main tests to diagnose GERD: endoscopy, esophageal pH monitoring, or manometry.
Acid reflux diagnosis depends on whether you experience complications in addition to the classic symptoms.
A visit to your primary care physician or gastroenterologist will guide you to the proper steps to your assessment and treatment of acid reflux. Your doctor can use your symptoms and a physical examination to make a clinical diagnosis of GERD; however, it will be in your best interest to confirm that your symptoms are indeed GERD and not something else. *Please follow your doctor's specific instructions for preparing for any medical procedure and understand that below is only a quick explanation of what to expect.
1. Upper Endoscopy is necessary to confirm a diagnosis of GERD. An upper endoscopy allows the doctor to visualize the structure and condition of the esophagus for signs of inflammation, ulcers, polyps, changes in cell tissue, erosion, narrowing, or any signs of disease or tumors. An endoscopy also allows the doctor to collect a sample of your tissue for further tests. If untreated, GERD can eventually change the cells and tissue of your esophagus, which can lead to esophageal cancer.
The upper endoscopy is a non-surgical procedure, performed by a general surgeon, that lasts about 15 minutes. You should not eat or drink 6 hours before the procedure, and you are given a mild sedative to help ease the discomfort. While you are laying on your side, the doctor examines your esophagus using a thin scope with a tiny camera and light at the end.
2. What if your endoscopy had normal findings, and you still have GERD symptoms? What if you have been taking prescribed acid-reducing medication, and it did not help your symptoms? A pH Monitoring test is an assessment that can confirm GERD by allowing the doctor to analyze the amount of stomach acid that goes into the esophagus, how long the acid stays in the esophagus, and the efficiency of the stomach acid leaving the esophagus.
The 24-Hour Ambulatory pH Monitoring test can be conducted in one of two ways. One, a tiny probe with a sensor is inserted through your nose to just above your lower esophageal sphincter. As with the upper endoscopy, you should not eat or drink several hours before the procedure or take prescribed acid-reducing medication. The doctor uses a numbing spray in your nostril before the lubricated probe is placed. After the tube is in place, you are encouraged to continue your typical day, eating and drinking as you normally would. The following day you will have to return to have the probe removed. The sensor records the data for 24-hours and is synced to a computer to be analyzed. Another method of the pH Monitoring test is conducted by swallowing a disposable capsule, which wirelessly measures and analyzes data during your day.
3. With symptoms of GERD that involve difficulty swallowing, pain when swallowing, or regurgitation, your doctor may need to assess the function of your esophagus. More specifically, your doctor will want to measure how well your esophagus moves food or drink to your stomach and the performance of the esophageal sphincters to open and close properly. Esophageal manometry is a test that measures pressures in your esophagus as you swallow, as well as the speed and patterns of the swallowing contractions.
The esophageal manometry procedure involves a tiny probe being inserted into your nasal passage to your stomach. The doctor uses a numbing lubricant or spray to ease any discomfort from the tube placement, and the procedure takes 10-15 minutes. After the tube is inserted, you will be asked to lie on your side and sip a small amount of water so that the sensors can measure the muscle activity in your esophagus.
Prolonged damage to your esophagus from GERD can lead to several complications if left untreated. There are several treatment options that can prevent further damage and complications such as ulcers, narrowing, precancerous tissue changes, and esophageal cancer.
Treating GERD can include any or a combination of these four targets:
lifestyle changes, medication, endoscopic therapy, and/or surgery.
1. There are many lifestyle and dietary changes that typically improve acid reflux symptoms. The most effective change would be to lose excess weight if you are overweight or obese. Extra weight puts pressure on the lower esophageal sphincter and allows stomach acid to reenter the esophagus. Eliminating or avoiding the following from your diet can reduce acid levels and improve the function (speed and pressure) of your esophagus: caffeine (coffee, sodas, etc); acidic foods (tomatoes, citrus fruits, spicy foods); chocolate; fatty foods; alcohol; peppermint. Eating very large meals, eating too quickly, not chewing food thoroughly, and wearing tight fitting clothing can contribute to reflux. After meals, you should remain upright for at least 3 hours before lying down or elevate your head when lying down. Another lifestyle change - quit smoking. Smoking contributes to some of the worst GERD complications, including esophageal cancer.
2. There are many medications that can be use to prevent reflux, treat the symptoms of reflux and/or heal the lining of the esophagus. Some medications neutralize stomach acid, decrease production of stomach acid, or strengthen muscles in the esophagus.
Antacids are a group of medications that neutralize stomach acid. The pH of our stomach acid normally 1.5 to 3.5 (where 1-7 is acidic, 7 is neutral, and 7-14 is alkaline). The ingredients in antacids include calcium, magnesium, sodium bicarbonate, or aluminum, all of which help to bring acid levels closer to neutral. Some antacids are Tums, Mylanta, Alka Seltzer, Milk of Magnesia, etc. Antacids are not meant to be taken on a daily basis, unless discussed with your doctor, and are to treat mild or infrequent symptoms of heartburn or indigestion.
Histamine (H2) blockers are a group of medications that aim to decrease the production of excess stomach acid. Histamine is a chemical that stimulates the cells in your stomach lining to produce acid; When the histamine is blocked, the production of stomach acid is decreased. Some H2 blockers are Pepcid and Tagament; Zantac was recalled in 2020 due to its unacceptable levels of a probable cancer causing chemicals. H2 blockers are usually effective 60 minutes after taking and can last 4-10 hours.
Proton Pump Inhibitors (PPI) are a group of medications that aim to decrease the production of stomach acid, usually more effectively than H2 blockers. The 'proton pump' is an enzyme that controls acid production. The enzyme is blocked and thereby decreases production of stomach acid. Some PPIs are Prilosec, Protonix, Nexium, Prevacid, etc. As with all medications, PPIs can have more serious side effects than H2 inhibitors, as they are metabolized by the liver and can also mask gastric cancers.
Prokinetic agents are medications that help strengthen muscles in the gastrointestinal tract, more specifically the lower esophageal sphincter. These medications help control reflux in that the food empties into your stomach quicker, not allowing much opportunity for refux. Prokinetics can have serious effects; for example, Reglan, puts you at risk for neurological conditions.
3. An alternative to long term medication trials is endoscopic therapy. Recent research into endoscopic therapies have surfaced and revealed popular options.
Stretta uses endoscopy to deliver radio frequency energy into the lower esophageal sphincter. This procedure takes 45 minutes under sedation but does not require an overnight hospital stay. You need a soft diet for 2-3 days, and you can be weaned off of PPIs in approximately one month.
Transoral Incisionless Fundoplication (TIF) uses endoscopy to repair or recreate the esophageal valve. This procedure does not use incisions but does require an overnight hospital stay. After 3-5 days, you can resume normal activity. There are several other endoscopic treatment options that your doctor may recommend. The main goal of endoscopic therapies is elimination or significant reduction of reflux and not having to stay on medication indefinitely.
4. When other attempts at treating reflux have failed, your doctor may recommend surgery. The Nissen Fundoplication is a surgical procedure, which can be laparoscopic or through an open approach, where the top part of your stomach is sewn 360 degrees around the LES. This procedure strengthens the lower esophageal sphincter to prevent further reflux. This procedure requires 1-2 days in the hospital depending of the type of surgery and a soft diet is recommended for 7-10 days after surgery. Most people return to normal activity in a few days.
Of the many treatment options, the safest route would be changing your lifestyle and diet. Medications are helpful, but can cause serious side effects. Endoscopic therapy and surgery can eliminate reflux and allow freedom from medication; however, these are invasive and are not 100% guaranteed. Most importantly, you cannot ignore treatment regardless of side effects or medical procedures. The consequences of not embracing treatment are far worse.
If you have a history of acid reflux, experience fullness in your throat, or frequent coughing while eating you may have dysphagia and benefit from a more thorough assessment.
Contact Louisiana Voice and Swallow Solutions for additional information at (225)269-9971.