Acid Reflux

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Table of Contents
Symptoms of Acid Reflux
Causes Of Acid Reflux
Are IBS And GERD/Acid Reflux Linked?
Can Stress Cause Acid Reflux?
Lifestyle Changes For GERD
Complications Of GERD
Treatments
Further Reading And References

Symptoms of Acid Reflux

The main symptoms of acid reflux are:

a burning sensation in the middle of your chest (heartburn)
stomach acid in the mouth which results in an unpleasant sour taste (1)

Common symptoms also include:

sense of a lump in the throat
abdominal bloating/discomfort
gas
chronic cough
feeling that food is trapped behind the breastbone or in the throat
nausea after eating
burning sensation that begins at the sternum and radiates up toward the neck
intense sharp pain behind sternum with radiation to the back

(3)

Acid regurgitation (refluxed material into the mouth) is another common symptom. But numerous less common symptoms other than heartburn may be associated with GERD.

These less common symptoms may include:

belching
difficulty or pain when swallowing
waterbrash (sudden excess of saliva)
dysphagia (the sensation of food sticking in the esophagus)
chronic sore throat
laryngitis
inflammation of the gums
chronic irritation in the throat
hoarseness in the morning
bad breath

(2)

hiccups
wheezing
ear ache

(3)

Acid reflux episodes of usually more than twice a week for several weeks at a time are diagnosed as Gastroesophageal reflux disease (GERD) (4).

Causes Of Acid Reflux

At the end of your esophagus is a circular band of muscle called the lower esophageal sphincter (LES) which is meant to relax and open when you swallow, then tighten and close again afterwards. When the LES doesn’t tighten or close properly, this allows the contents of your stomach to rise up into your esophagus causing acid reflux. (5)

The stomach contains a strong acid (hydrochloric acid) used in the process of breaking down food and protecting against pathogens such as bacteria. Stomach lining is built to protect it from this acid, but the esophagus does not have this protection. (4)

Sometimes it’s caused or made worse by:

certain food and drink – such as coffee, tomatoes, alcohol, chocolate, onions, garlic and fatty or spicy foods
being overweight
smoking
pregnancy
stress and anxiety
some medicines, such as anti-inflammatory painkillers (like ibuprofen)
a hiatus hernia – when part of your stomach moves up into your chest (1)

low levels of physical exercise
medications, including drugs for asthma, calcium-channel blockers, antihistamines, painkillers, sedatives, and antidepressants
a diet low in dietary fibre
eating large meals
lying down within 2 to 3 hours of eating a meal
consuming chocolate, carbonated drinks, and acidic juices

(4)

Some believe that acid reflux is due to low stomach acid, suggesting taking additional acid to help treat it. However, there is currently no scientific evidence to support this theory. (31)

Some also suggest that you can test whether your stomach acid is low by a bicarbonate of soda test and checking how long it takes you to belch. According to this test I had low stomach acid, however, when I took the remedy (apple cider vinegar), my reflux got worse. I was also recommended Hydrozyme which contains Betaine Hydrochloride, but this put me in extreme pain and did not help at all.

Are IBS And GERD/Acid Reflux Linked?

A 6,000 people study published in the World Journal of Gastroenterology found that about 63 percent of those diagnosed with IBS had GERD symptoms, too, which backs up other studies that there is a strong link between IBS and GERD. Having both GERD and IBS was more common in women and both conditions together made all symptoms worse. A study published in The American Journal of Gastroenterology found that having GERD symptoms was 4 times higher for IBS sufferers than those without IBS. This could be down to both conditions being related to an overall increase in the sensitivity of the digestive system in patients suffering from these conditions, with patients becoming uncomfortable at lower thresholds than healthy subjects (visceral hypersensitivity). Both GERD and IBS are now considered by experts to be motility disorders relating to the disordered passage of food through the digestive system. (6)

I have found that being constipated is more likely to trigger acid reflux. In fact, I could almost guarantee that when I had episodes of IBS-D (i.e. my system would clear out), I wouldn’t get reflux, but when I had severe IBS-C I would. I have hypothesized that this is due to food hanging around for longer in the colon, with bacteria having more time to feed off the waste, producing more gases, which increases pressure in the gastrointestinal system, thus weakening the LES. There may also be the situation of this slowing gastric emptying so that acid and foods have more chance to leak into the throat. However, I have not been able to find any concrete studies that back this up. Part of my strategy for keeping my acid reflux under control is to ensure bowel regularity through diet. People will have different reasons for their reflux. For example, reflux caused by hiatus hernia may be more difficult to control due to it being related to a physical problem. However, keeping regular may help a little, but this would be down to individual trial and error.

Can Stress Cause Acid Reflux?

From a 1993 study it was found that stress does not increase gastric acid exposure, however, those who were anxious and stressed reported having more painful acid reflux symptoms (32). In fact, when stressed, a person becomes more sensitive to smaller amounts of acid in the esophagus (7). In theory, stress may turn up pain receptors in the brain resulting in sensitivity to slight increases in acid in the esophagus. Prostaglandins, which normally protect the stomach from the effects of acid (33), can also be depleted by stress (34) increasing sensitivity to acid exposure and the perception of discomfort.

Lifestyle Changes For GERD

Do:

eat smaller, more frequent meals^*1
raise one end of your bed 10 to 20cm by putting something under your bed or mattress – your chest and head should be above the level of your waist, so stomach acid does not travel up towards your throat^*2
try to lose weight if you’re overweight
try to find ways to relax

Don’t:

have food or drink that triggers your symptoms^*3
eat within 3 or 4 hours before bed
wear clothes that are tight around your waist
smoke
drink too much alcohol
stop taking any prescribed medicine without speaking to a doctor first

(1)

*1 There may be some controversy around eating smaller and more frequent meals in terms of having enough space between meals for your migratory motor complex to run in your small intestine to ensure waste is regularly swept into your colon – see SIBO. Nevertheless ensuring that you don’t over-eat at meal times and to the point of being overly full can only help.

*2 With raising the head of your bed, to allow your body to get used to the new sleeping position, you may want to raise the head of your bed just 3 inches initially and then move to the recommended 6 inches once you are used to 3. The maximum recommended elevation is 8 inches. You may find that you slide a bit at this level. Note that you may have muscle aches and/or stiff neck whilst your body gets used to the new position during the first week or two. (9) In a study it was found that elevating the head of the bed led to some relief from heartburn and related sleep disturbance by reducing esophageal acid exposure and acid clearance time. (10) Some may be concerned that having a bed on an incline may be detrimental to health, however, there is a possibility of it helping in other ways including improving blood circulation and respiratory function (9). Inclined bed therapy goes back to Ancient Egyptian times (11). You can purchase robust 20cm high or adjustable bed risers online. Alternatively you can purchase a bed wedge pillow which raises your torso by 20cm, but as a side sleeper I found that this gave me hip issues when using this long term.

*3 Foods that may trigger GERD include: Caffeine, Chocolate, Peppermint, Alcohol (red wine pH = 3.25), Carbonated beverages (cola pH = 2.75), Citrus fruits (orange juice pH = 3.25), Tomato-based products (tomato juice pH = 3.25), Vinegar (pH = 3.00) and Fatty foods (20). I have even found the aroma from mint toothpaste to weaken my LES and aggravate GERD, so I have switched to a non-mint toothpaste (Kingfisher Fennel with Flouride Toothpaste), which is available from a number of health stores. You may also have issues with mouth washes. Paradoxically many heartburn medications are mint based so you may need to avoid the mint versions of those products. You may also want to consider the acidity levels of certain fruits – lower acid options include: dates, figs, melon, papaya, berries, bananas and coconut (21). There are useful tables containing the PH values of certain foods here (22), (23) (24) (25). The lower the PH number, the higher the level of acidity. I normally don’t advocate the use of vitamin C supplements, but if you need to take them and to avoid the acid from ascorbic acid based products, you can purchase Ester C, which is buffered with calcium ascorbate to neutralize the acidity. Note the Ester C link is to a US supplier. If you are based in the UK you will need to check the current rules on any charges related to the import of US goods to the UK.

Complications Of GERD

Symptoms of persistent acid reflux/GERD must not be ignored and must be discussed with your doctor.

The NHS recommends to see your GP if:

you are not helped by lifestyle changes and pharmacy medicines
heartburn is experienced most days
there are other symptoms, like food getting stuck in your throat, frequently being sick or losing weight for no reason

(1)

There can be long term implications of untreated acid reflux/GERD causing chronic inflammation in your esophagus which could lead to:

narrowing of the esophagus (esophageal stricture). The formation of scar tissue which narrows the food pathway leading to swallowing problems. The scar tissue is due to damage to the lower esophagus from stomach acid
an open sore in the esophagus (esophageal ulcer). Formation of an esophageal ulcer causing bleeding, pain and difficulty in swallowing due to stomach acid wearing away esophageal tissue
precancerous changes to the esophagus (Barrett’s esophagus). Changes in tissue from damage from acid are associated with an increased risk of esophageal cancer

(8)

A diagnosis of Barrett’s esophagus will require life long monitoring.

Treatments

If your GP has ruled out other causes of your symptoms you may be offered a prescription for PPIs (proton pump inhibitors) which reduces the level of acid in your stomach. Ideally you want to make lifestyle changes first since there is controversy over long term use of PPIs (12) (13) (14) (15) (16) (17) (28) (29) (30). Since GERD/acid reflux and IBS often go hand in hand, pursuing improvements in your IBS symptoms (e.g. Alflorex probiotic and/or FODMAP elimination and reintroduction diet) and reducing stress may improve your GERD/acid reflux symptoms.

Sometimes the benefits of long term PPI use outweigh the risks (e.g. Barrett’s Oesophagus, oesophageal stricture dilation, and gastroprotection for NSAID treatment). (17) It is best to speak to your GP about your own situation.

You may be prescribed one of the cheaper PPIs first. I found that Omeprazole made me so dizzy that I was unable to work. I didn’t realise at the time that I didn’t need to suffer with this and that there are other options available. I was subsequently prescribed Nexium (esomeprazole) which is more expensive for the GP practice, but I experienced fewer side effects. I have only used PPIs in short bursts (no more than 6 months) to help heal a sore chest from reflux, which used to occur during times of stress. Eventually, I started to get an itchy rash on my legs even with the Nexium so I needed to discontinue it.

I also tried Domperidone which helps to speed up stomach emptying. However, there now seems to be warnings against this drug in relation to potential serious cardiac side effects (18).

There are also surgery options in severe cases of GERD/acid reflux that cannot be controlled by other means. This involves tightening the LES (19). There is also a device called RefluxStop, which involves a type of anti-reflux surgery for those with large hiatal hernias, that has had a good level of success when trialled by the NHS (35).

A possible natural alternative to PPIs is deglycyrrhizinated licorice (DGL). 58 adults with GERD where studied over 8 weeks whilst being administered a low dose of glycyrrhetinic acid in combination with standard treatment. Symptoms were significantly improved as a result. A two year study of 58 adults with GERD found that daily use of licorice root was more effective at reducing symptoms than commonly used antacids (26). Note that whole licorice should be avoided for this purpose since it can increase blood pressure, but DGL has the component removed that increases blood pressure. DGL is available in powder or tablet form. Tablets can be sucked slowly 15-20 minutes before every meal and at bedtime, or take one-half teaspoon of the powder before meals. Each should be dissolved in the mouth and allowed to slowly trickle down the throat. This provides a protective coating for the throat. DGL can be taken as long as you have symptoms (27). I have used this product in the past: FSC DGL Liquorice – suck 1 tablet 20 mins before meals and 1 before bedtime. If you are concerned about the sorbitol (FODMAP) in the FSC product, it is available in pure powder form from Vital Nutrients.