[Image source: iStockphoto]
or try the A-Z Library
Fact File
Reflux
Reflux is the regurgitation of acid stomach contents back into the oesophagus, and is the cause of heartburn - that unpleasant, burning feeling that wells up from the pit of the stomach, and travels up your chest and into your throat after a rich or fatty meal.
Published 25/09/2006
[Image source: iStockphoto]
Background
Food travels a long way on its journey from entry to exit points in our bodies. And it has a way of reminding us just exactly where it is at each stage of its journey.
Just ask anyone who suffers from heartburn – that unpleasant, burning feeling that wells up from the pit of the stomach, and travels up your chest and into your throat after a rich or fatty meal.
Heartburn can last anywhere from a few minutes to several hours after a meal. It's often accompanied by nausea, a bloating feeling in the stomach, and a bitter taste in the mouth.
The symptoms are caused by the regurgitation of acid stomach contents back into the oesophagus – a phenomenon known as by gastroesophageal reflux. As the name is a meal in itself, this is often shortened to 'reflux'.
Why does it cause such pain and discomfort? It all has to do with the way food is digested in the upper part of the gut.
Causes
The stomach is a bag designed to store food while the protein in that food is broken down into smaller units called amino acids.
The enzyme responsible for protein breakdown, called pepsin, requires a very low pH – a very acidic environment – to work. To maintain this pH, specialised cells in the stomach lining secrete hydrochloric acid. Nasty stuff!
Normally, this acid would destroy any body cells it came into contact with. So other specialised cells secrete mucus to protect the stomach lining from its corrosive effects.
But the oesophagus – the tube that leads from the throat to the stomach (in everyday terms called the gullet) – has no such protection. There is a sphincter that acts as a valve where the oesophagus meets the stomach, but it isn't perfect, and some acid does escape back into the oesophagus. This may irritate and sometimes damage the oesophageal lining, and we feel this as heartburn.
Reflux tends to run in families, and to be worse during pregnancy. People who get it are often overweight, smoke, and drink alcohol.
It also becomes more common with age. This may be because older people are more likely to develop a hiatus hernia – in which a portion of the stomach moves up through a hole in the diaphragm into the chest. Hiatus hernia is a harmless condition, but it does disrupt the functioning of the sphincter, and so is often associated with reflux.
Some foods seem to aggravate reflux, either by irritating an already inflamed oesophageal lining, or by interfering with the proper workings of the sphincter. The culprit foods include acidic foods (like tomatoes and citrus fruits), coffee, chocolate, onions, garlic, and foods that contain large amounts of fat.
For the great majority of people, reflux is an occasional nuisance – nothing more than a reminder that every glass of red wine, every plate of oysters and every bar of chocolate has its price.
But for 15 to 20 per cent of people, it's frequent enough to be debilitating. And in about a third of reflux cases, the acid can actually damage the oesophageal lining. In rare cases, this can produce scarring and even cancer of the oesophagus.
Symptom relief
Should you see a doctor if you have symptoms of reflux? Not necessarily. There are some things you can do to relieve symptoms:
- Stop smoking, lose weight (even a small amount of weight loss helps), and avoid the foods that cause it.
- Leave a couple of hours between your last meal at night and going to bed (this allows time for digestion).
- Elevate the head of the bed. This means that when you're asleep, reflux of acid into the oesophagus is less likely, as it's going against gravity. Six inches of elevation is recommended.
If these measures don't work, you can try taking an over-the-counter antacid. These mostly contain calcium carbonate, an alkaline preparation that helps neutralise the effects of stomach acid. It helps, but it won't get rid of the symptoms altogether. (It's also dangerous to use it continually.)
If heartburn is a continual or severe problem, it's a good idea to see your doctor. You should definitely see your GP if you have any of the following:
- Unexplained weight loss.
- Severe pain in the chest which worsens with exertion.
- Difficulty swallowing.
- Vomiting blood.
These symptoms may indicate something more serious than just reflux is going on.
Studies have shown that people with heartburn are at increased risk of gastroesophageal cancer. However, the risk of that someone who has heartburn getting oesophageal cancer is still very low. What it does mean though, is that someone who is found to have oesophageal cancer, will probably have heartburn.
Diagnosis
Your doctor should be able to diagnose reflux easily from your medical history. But sometimes you may be sent for further tests – if the diagnosis is uncertain, for example, or if the symptoms are severe and haven't responded to treatment.
The test most commonly performed is called endoscopy. This involves passing a flexible fibre-optic telescopic tube, with a tiny camera at the end, through the mouth and down into the oesophagus. Through the endoscope, the oesophageal lining can be inspected for inflammation or other disease. Endoscopy is usually done by a gastroenterologist as a day-only procedure with light sedation.
New technology may at some point reduce the need for endoscopy. The 'pillcam', which isn't available in Australia yet but used in the US, is a disposable camera in a tiny pill. After it's swallowed, the pillcam transmits images of the oesophagus to a receiver pack worn by the patient. It's much more comfortable than traditional endoscopy and doesn't require sedation. The pill is excreted in 24 to 48 hours. However, the patient will still need to have an endoscopy and biopsy if the pillcam reveals a condition like an ulcer or a cancer.
Treatment
If the simple measures mentioned above don't work, there is a range of prescription drugs to treat reflux.
Some, like cimetidine, ranitidine, famotidine and omeprazole, work by reducing the amount of acid the stomach produces, thereby reducing the quantity of acid refluxing into the oesophagus. Others are muscular stimulants – they act by tightening the lower oesophageal sphincter. Others, like sucralfate, stick to the lining of the oesophagus to help protect it from the acidic stomach contents.
While these drugs give relief, they don't cure the condition. So people who get frequent troublesome reflux may need to be on these drugs continuously.
In severe cases, surgery is an option. This involves a surgeon tightening the lower oesophageal sphincter. Most people who have surgery still have to take drugs, however. So surgery is only usually only recommended as a last resort.
Reviewed by Dr Anne Duggan, Associate Professor, John Hunter Hospital
Updated 19/01/2007