- What is Acid Reflux (Gastro-Oesophageal Reflux Disease; GORD)
- Statistics on Acid Reflux
- Risk Factors for Acid Reflux
- Progression of Acid Reflux
- Symptoms of Acid Reflux
- Clinical Examination of Acid Reflux
- How is Acid Reflux diagnosed?
- Prognosis of Acid Reflux
- How is Acid Reflux treated?
- Acid Reflux references
What is Acid Reflux
Image edited by Dr.Dt.E.Bihter Gürler
Acid reflux involves inflammation and irritation of the lower oesophagus due to the reflux of food and gastric acid. This reflux of gastric contents is spontaneous and involuntary.
Below is an endoscopic image showing ulceration of the lower end of the oesophagus caused by the refluxed gastric acid.
Figure 1: Inflamed oesophagus due to GORD.
Statistics on Acid Reflux
Acid reflux is extremely common: as many as one in five people experience acid reflux symptoms at least once a week, and one in ten people have acid reflux symptoms every day.
Acid reflux may also occur in infants and children. However, in this age group it is important to distinguish between the relatively rare occurrence of acid reflux, and the common and normal condition of ‘physiological reflux’. Physiological reflux usually develops during the first year of life with symptoms of vomiting or irritability, but soon resolves without the need for treatment and with no long-term consequences. Reflux of stomach contents, with or without associated disease of the oesophagus, is common in infants due to immaturity of the stomach and oesophagus and their high fluid intake.
Risk Factors for Acid Reflux
Predisposing factors for reflux include:
- Cigarette smoking;
- High caffeine intake (e.g. coffee, tea or chocolate);
- Excess alcohol ingestion;
- Eating large meals (especially late at night) or meals high in fat;
- Hiatus hernia;
- Family history: There is some genetic predisposition to reflux; and
- Some drugs (particularly those used to treat high blood pressure and angina)
The oesophagus is connected to the top of the stomach. The lower end of the oesophagus has thick muscle layers (called a sphincter) that keep the oesophagus closed and normally prevent food going backwards up the tube. In infants and children, a large amount of reflux is caused by intra-abdominal pressures exceeding the pressures across the lower oesophageal sphincter. Thus abdominal straining and delayed gastric emptying can increase the likelihood of reflux.
Some conditions associated with neurological impairments may also predispose your child to acid reflux.
Progression of Acid Reflux
Without acid reflux treatment, the long-term damage to the oesophagus in acid reflux disease can lead to a number of complications. These include development of strictures (tight bands) across the oesophagus, which may make swallowing difficult, and ulceration of the stomach, which may lead to bleeding into the gut.
One in ten patients with acid reflux, and in particular those with long-standing or severe acid reflux, will develop Barrett’s oesophagus. This is a condition where the normal lining of the oesophagus is replaced by a different type of tissue, normally found in the intestines, in response to long exposure to damaging acid or bile.
Patients with Barrett’s oesophagus are more likely to develop strictures or ulceration, but most importantly they have a much higher chance (30-40 fold higher relative risk) of developing adenocarcinoma of the oesophagus.
In infants and children, mild acid reflux symptoms usually resolve within the first 12 months of life. As the child gets older, the gastrointestinal system matures and a more solid diet and upright posture also help to prevent reflux. For these children, reflux is more of a nuisance and doesn’t cause any real problems. However, a small percentage of children will go on to develop true acid reflux (gastro-oesophageal reflux disease). These children may require more investigations and treatment to prevent complications (see below).
Symptoms of Acid Reflux
Common acid reflux symptoms include:
- Acid regurgitation (a bad taste in the mouth, particularly when lying down);
- Difficulty swallowing (known as ‘dysphagia’): This may be due to development of a stricture (tight band) across the oesophagus, or possibly due to cancer of the oesophagus;
- Nausea and vomiting: If the oesophagus is eroded you may have bleeding which causes coffee ground coloured vomit;
- Waterbrash (excess saliva production in the mouth);
- Chest pain: This is usually a burning discomfort behind the breast bone (and sometimes spreading to the back) 30-60 minutes following a meal. This chest pain can mimic other diseases such as angina;
Your doctor will ask you several questions about your symptoms including their onset, duration and what makes them better or worse. The most classical presentation is heartburn that is aggravated by bending, stooping or lying down and may be relieved by antacids. In acid reflux regurgitation of food and acid into the mouth gives a bitter, acid taste and occurs especially when lying flat or bending over. Rarely, acid reflux may irritate the lungs, producing cough or symptoms of asthma at night. You may also notice that you have difficulty swallowing.
Symptoms of acid reflux in infants and children tend to be quite different. The most common symptoms of gastro-oesophageal reflux disease in children are vomiting and regurgitation. There are however lots of different conditions that can lead to similar symptoms. It is important that you have your child checked by a doctor as occasionally more serious diseases such as foreign bodies, bowel obstruction or inflammatory bowel disease may be present.
You should look out for the following symptoms of GORD:
- Infants: feeding difficulties (including refusing to feed, pulling away, comfort feeding or crying during feeding), failure to thrive, irritability, excessive crying, cough, cyanotic episodes (going blue in the lips or face), apnoeas (short periods of not breathing), sleep disturbances (restless during sleep or nighttime wakening.), hiccoughing.
- Children: complaints of a ‘bad taste’ in the mouth, nausea, heartburn, recurrent chest infections such as pneumonia, weight loss, hoarseness of the voice, chronic cough or asthma.
Symptoms in children are very variable and like adults the number and degree of symptoms does not tell us how severe their reflux actually is. Older children are better able to describe the classical symptoms of heartburn, chest pain and a sick or sour taste in the mouth. In younger children diagnosis is much more difficult and relies on careful observation of their habits and behaviour.
Clinical Examination of Acid Reflux
Examination is not usually very useful in the diagnosis of acid reflux. Most of the diagnosis is from typical symptoms and some investigations. There may however be evidence of weight loss as a consequence of dysphagia or weight gain as a result of eating to relieve symptoms.
How is Acid Reflux diagnosed?
The diagnosis of acid reflux can often be made without investigation, especially in young patients with typical symptoms and without concerning features such as vomiting, weight loss or anaemia. Investigations into acid reflux may be recommended in older patients with atypical features or if complications are suspected.
Common acid reflux investigations include:
- Barium swallow and meal: You will be given a special radio-labelled dye to swallow, and x-rays are then taken of the throat, oesophagus and stomach. The dye allows visualisation of how the ‘meal’ moves into the stomach and whether any acid reflux occurs. Strictures may also be visible.
- Endoscopy (oesophagogastroscopy): A fibre-optic telescope is passed through your mouth to allow direct visualisation of the lining of the oesophagus. Samples of the lining (biopsies) can also be taken for examination under a microscope. This allows for the diagnosis of Barrett’s oesophagus and other complications, including cancer, which can be found in a small number of patients.
- pH monitoring: The level of acid in the oesophagus can be measured to detect reflux. However just because there is acid doesn’t mean there is necessarily any damage or disease.
Investigations in children
Like adults, the diagnosis of reflux in children is largely dependent on history and examination. Physiological jaundice does not require further tests. However if your child has growth problems, pain or respiratory symptoms, your doctor will usually order more tests. The same investigations listed above can be used for children. Barium investigations are the most commonly used but are not very reliable at detecting signs of reflux. They can however be useful in detecting strictures (narrowing) or other structural problems.
Prognosis of Acid Reflux
With appropriate treatment of acid reflux, prognosis is excellent. Symptoms almost invariably resolve and the inflammation of the oesophagus caused by acid damage can heal in the majority of patients. However, recurrence is common if therapy is stopped. Surgery is available for severe cases.
The presence of Barrett’s oesophagus places you at a much higher risk of developing adenocarcinoma of the oesophagus. If you are male, elderly, obese, smoke and have severe and frequent reflux symptoms, you are at greatest risk. However, the overall risk of developing adenocarcinoma of the oesophagus is still low and only approximately 2-3% of affected patients will die from this disease.
As forementioned, the majority of children will out-grow their condition and most symptoms will resolve by two years of age. Long-term complications of gastro-oesophageal reflux in children are rare.
How is Acid Reflux treated?
Management of GORD often requires a combination of lifestyle changes, drugs and occasionally surgical interventions. The aims of treatment are to relieve your symptoms, improve your quality of life, heal the oesophagus and avoid any complications.
Below is an overview of the treatments available for GORD. An overview of possible treatments for your reflux is outlined below. Note that up to 50% of acid reflux patients respond well to simple antacids and general measures outlined below.
Simple techniques to try first include:
- Weight reduction if overweight;
- Reduction or cessation of smoking and alcohol consumption;
- Reduction or cessation of caffeinated drinks such as coffee and tea;
- Elevation of the head of the bed, or use of a wedge pillow to avoid sleeping flat;
- Dietry changes: eating a low fat diet; avoidance of spicy foods and tomato products, especially at night; and allowance of at least three hours between the evening meal and lying in bed.
- Simple antacids: You can access several antacid preparations from your local pharmacy or supermarket. These agents might be enough to control infrequent acid reflux symptoms. These work by ‘neutralising’ the acid your stomach produces.
- Acid reduction drugs: There are two main classes of drugs used to reduce the amount of acid produced in your stomach. These are proton pump inhibitors (PPIs) and histamine-2 receptor antagonists. The former type have been shown to be the best at reducing symptoms and healing damage to the oesophagus, but they are expensive.
- Prokinetic agents: These drugs enhance emptying of the oesophagus and stomach so that no food or stomach contents are sitting in the stomach to reflux. These agents are most appropriate for acid reflux patients who have problems with oesophagus emptying contributing to their acid reflux symptoms.
- Mucosal protective agents can be used to produce a protective coating or lining on the oesophagus.
Acid reflux surgery
Nissen fundoplication is the most popular type of anti-reflux surgery. This involves the wrapping of the upper stomach around the lower oesophagus (see right for normal anatomy of the gastro-oesophageal junction). It is designed to increase pressure of the sphincter at the bottom of the oesophagus and prevent acid reflux from occurring. Treatment of oesophageal strictures usually involves widening of the stricture during endoscopy. Surgery may occasionally be required to relieve difficulty in swallowing.
Management of Acid Reflux in Children
In most infants with acid reflux symptoms will disappear completely by 12 months of age. It is therefore important that medical or surgical acid reflux treatments are only offered where absolutely necessary. Simple conservative measures and lifestyle changes are generally the best treatments for your child.
You should remember that mild reflux is generally not a serious condition and that your child is otherwise well and healthy. Your doctor can help explain the condition more so that you understand that it is usually better for your child NOT to have extensive investigations or multiple drug therapies. This will avoid unnecessary side effects from unnecessary treatments.
Treatment options for children include:
- Infants with mild acid reflux reflux may respond well to simple thickening of their feeds. You can find special anti-reflux formulas in supermarkets. It can also be helpful to keep your child upright for approximately half an hour after feeds. Laying your child on their stomach also reduces reflux symptoms but is associated with an increased risk of sudden infant death syndrome (SIDS). You can try to determine what makes your child symptoms worse so appropriate changes can be made.
- Acid suppressing agents may be appropriate in some infants, particularly if your child has chronic diseases of the airways or some neurological disability. The agents used are similar to those for adults, and include proton pump inhibitors and histamine-2 receptor antagonists.
- Children with severe acid reflux, persistent vomiting and failure to thrive may require continuous feeding through a nasogastric tube. This is a tube passed through the nose and down into the stomach, through which nutrient-rich pureed foods can be fed. This allows your child to catch up on their growth and avoid medical problems from poor nutrition.
- Nissen fundoplication is a surgical procedure also used in some children with very severe disease. However the risks and complications of surgery must be carefully considered and surgery is often not performed until your child is older than three years of age.
Looking after a child with reflux can be frustrating and exhausting. It is important that you also look after yourself whilst caring for your child and arrange appropriate help and support. Also remember that this illness is not your fault and that you are not doing anything wrong. If you have any other questions regarding your child’s condition or appropriate treatment, make sure you discuss them with your doctor.
|View the Reflux Information leaflet.|
|For more information on acid reflux and heartburn and related investigations, treatments and supportive care, Acid Reflux and Heartburn.|
Acid Reflux references
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