Acid Reflux: Definition, Occurrence, Cause, Symptoms, Diagnosis and Treatments

Acid Reflux Overview

Acid reflux is the backflow of stomach contents into the oesophagus, causing symptoms like heartburn, troubled swallowing and regurgitation. If the symptoms occur more than twice weekly, it is called acid reflux disease (ARD) or gastroesophageal reflux disease (GERD). The stomach secretes a strong acid (hydrochloric acid), which helps digest food and kills the germs entering the mouth. A ring of muscles at the junction of the stomach and food pipe called the lower gastroesophageal sphincter (LES) works as a valve and prevents the backflow of stomach contents. The failure of LES, coupled with high pressure in the stomach, causes the backflow of stomach contents into the food pipe. 

Unlike the stomach, which has a mucus covering that protects it from the acid, the food pipe is not protected. So, a severe sensation of burning develops. Various conditions causing acid reflux are hiatal hernia, obesity, pregnancy, connective tissue diseases like scleroderma and any condition that causes increased stomach emptying time. The other risk factors are a sedentary lifestyle, smoking and certain medications like antidepressants, antibiotics, sedatives, painkillers, antihistamines and calcium channel blockers. Some dietary habits and foods like eating large meals, eating spicy and fatty foods, lying down immediately after a meal, and using sauces, acidic juices and carbonated drinks have an important role. It is a common condition, and a clinical review at the Research Evaluation Unit, Oxford PharmaGenesis, UK, in 2014 found that 5 out of 1,000 people experience acid reflux each year. 

Heartburn with discomfort and burning pain in the stomach are the major signs. The burning sensation moves from the stomach into the abdomen, chest, and throat. A bitter and sour taste is felt in the throat and mouth. The other symptoms are blood stools or vomit, bloating, nausea, dysphagia, burping, weight loss, dry cough, wheezing, sore throat, asthma, bad breath and chest pain. The symptoms are easy to identify. However, the doctors rely on tests like a biopsy, endoscopy, barium x-ray, oesophageal manometry, pH impedance monitoring, etc., as the symptoms are experienced in other conditions like pulmonary embolism, pain in the chest wall, pneumonia and heart attack. The untreated cases result in severe complications like reflux oesophagitis, strictures and Barrett's oesophagus. 

Various treatment options available are medications like H2 blockers, proton pump inhibitors (PPIs), antacids, sucralfate, potassium competitive acid blockers and prokinetic agents. In complicated cases, surgical options like fundoplication and implantation of magnetic devices and pain modulators like tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), etc., are used. Lifestyle changes like avoidance of late-night meals, taking smaller meals, maintaining good hygiene and weight, adding more fibre to the diet, leaving smoking and keeping the head elevated during sleep are useful. 

What is Acid Reflux?

Acid reflux is a gastrointestinal condition characterised by regurgitation of stomach contents back into the food pipe and throat in severe cases. The American Academy of Allergy, Asthma and Immunology defines it as a digestive disorder in which the acidic stomach contents, including food and liquids, back up into the food pipe. A repeated occurrence is a sign of gastroesophageal reflux disease (GERD). It is among the most common gastrointestinal disorders experienced by infants and adults alike. It is the consequence of structural, intrinsic and lifestyle factors that disrupt anatomical barriers between the stomach and oesophagus. 

The stomach contents are highly acidic with a pH of 1.5-2, and their entrance into the muscular and unprotected oesophagus or higher structures causes severe signs like heartburn, chest pain, acidic taste, difficulty swallowing, chronic cough, etc. According to the American College of Gastroenterology, a burning sensation under the breastbone is the most prominent symptom. 

How Does Acid Reflux Occur?

Acid reflux occurs when stomach acid flows back into the esophagus, the tube that connects the throat to your stomach. Although there is no single cause of acid reflux, over time, many causes and risk factors accumulate to cause it. The factors collectively cause the weakness and relaxation of the lower oesophageal sphincter, which prevents the backflow of stomach contents. Various factors triggering the acid reflux are;

Foods: Certain spicy, acidic, and fatty foods containing hot peppers, spicy sauces, fatty meats, dairy products, oil and butter trigger the acid reflux by causing the relaxation of the lower oesophageal sphincter and irritating the food pipe. 

Obesity and larger meal size: Obese people and those eating larger meals are at higher risk because both conditions create greater pressure inside the abdomen, pushing the contents outward. 

Poor habits: Poor dietary habits like lying down or reclining immediately after a meal facilitate the stomach contents flow into the food pipe. 

Smoking and drinking: Smoking and drinking alcohol decreases saliva production in the stomach and weakens the LES. Saliva protects the internal organs from acid. The carbonated drinks create gas bubbles in the stomach, resulting in increased pressure inside the stomach and causing relaxation of LES. The carbonated beverages often result in overeating.

Medical conditions: Some medications like nitrates, calcium channel blockers and antihistamines, hormonal changes associated with pregnancy, and anatomical conditions like hiatal hernia are sometimes responsible. 

Stress: Stress is not a direct cause; it exacerbates the situation by negatively influencing digestive health. 

The triggers vary from person to person, and many triggers are unique to a person. The identification of person-specific triggers is important for proper treatment and prevention. The feelings associated with acid reflux are different for different people. The common feeling is burning in the chest, particularly under the chest bone. The feeling of pain and discomfort sometimes extends into the throat. The food and acidic contents of the stomach flow back into the mouth and throat, causing a bitter and sour taste in the mouth. Frequent belching is found as the body tries to expel the gases from the stomach. Some people experience globus pharyngeus, a sensation of lumping in the throat, which causes dysphagia (difficulty in swallowing). 

The chest pain, as seen in the heart attack, is noticeable. Some people experience severe signs at night when they are in a sleeping position and experience a nocturnal cough. Repeated exposure to the acids corrodes the epithelium, causing irritation and inflammation, resulting in a persistent sore throat and hoarseness. The symptoms worsen while lying down as it facilitates the movements of stomach contents. 

What are the Causes of Acid Reflux?

There is no definitive cause, and a combination of different factors is responsible. The persistence of these factors leads to the development of a more severe form known as gastroesophageal reflux disease (GERD). The primary causes responsible are; 

Hiatal hernia: Hiatal Hernia is a situation in which a part of the stomach protrudes into the chest cavity through the diaphragm. Typically the diaphragm maintains pressure on LES, which helps to keep it close. In the case of a hiatal hernia, there is no more diaphragmatic support, and the stomach contents flow easily upwards as the weakened LES fails in its functions. A recent study published in The Saudi Medical Journal found that 48.6% of patients undergoing esophagogastroduodenoscopy (EGD) for GERD had hiatal hernia. 

Eating larger meals: Eating larger meals increases the workload on the stomach. The stomach increases the production of acids and enzymes to digest more food. Both factors favour the development of acid reflux. 

Defective peristalsis in the oesophagus: In a healthy person, the stomach contents reaching the oesophagus are neutralised by the bicarbonate salts present in the saliva and are pushed back by the peristaltic movements of the oesophagus into the stomach. Failure of oesophageal peristalsis results in acid reflux, as Diener and his colleagues noted that defective peristalsis was responsible for 21% of cases of GERD. 

Impaired mucosal defences of the oesophagus: The inner lining of the oesophagus is protected by chemical and physiological barriers. The prolonged exposure to the stomach contents beaches these defences. It results in damage to the inner lining of the oesophagus.

Fast eating: Fast eating and taking quick meals within a short time causes acid reflux as the stomach processes many foods rapidly. Improper chewing of food in the mouth increases the stomach's workload, and the foods stay for a long time in the stomach, which causes increased risk.

Taking snacks before bed: Lying down immediately and within 1-2 hours after a meal increases the chances of developing acid reflux. Eating snacks before bed is not a healthy habit. The health professionals recommend that the people experiencing the symptoms of acid reflux must not lie for at least 3 hours after a meal. A study published in the American Journal of Gastroenterology noted that a shorter dinner to bedtime less than 3 hours significantly increases the risk of GERD. 

Too early exercising after a meal: Lifting heavy weight or bending, particularly after a meal, causes the stomach acids to rise. Working out immediately after the meal increases the risk of acid reflux. 

Tight clothing: A tight waistband or belt exerts pressure on the stomach, causing the stomach contents to rise. Loosening the belt or unbuttoning the pants after a meal is helpful. David Mitchell at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow said that a tight waistband increases intragastric pressure and doubles the frequency of reflex events.

Delayed gastric emptying (gastroparesis): After performing its functions, the stomach gradually releases its contents into small intestines for further processing. A delay in gastric emptying causes the contents to stay in the stomach longer. The gastroparesis developing in response to certain medications, diabetes and nerve damage results in an increased contact time between stomach contents and LES and an increased risk of acid reflux. 

Increased acid production in the stomach: The stomach of healthy adults produces 1.5-3 litres of hydrochloric acid to digest food and kill the germs. The inner lining of the stomach is protected from the acid. The conditions like certain medications used to treat low stomach acid, gastrinomas (tumours that result in increased acid production), and Zollinger-Ellison syndrome cause increased production of stomach acids. It increases the likelihood of acid reflux. 

Pregnancy: The growing foetus in the uterus exerts pressure on all internal organs, including the stomach. It, coupled with hormonal changes during pregnancy, increases the risk of acid reflux in pregnancy. Heartburn during pregnancy is reported by 17-45% of pregnant women.  

Medications: Certain medications irritate the oesophagus and cause acid reflux as a side effect. Examples are painkillers like ibuprofen and aspirin and other medications and supplements like nitrates, anticholinergics, potassium supplements, sedatives and bisphosphonates (drugs used to treat bone diseases). 

Ageing: Ageing weakness in all muscles in the body, including the sphincters. Therefore, the risk of acid reflux is much higher in old age. More than 75% of cases of GERD are reported in individuals aged 35 or above. 

Medical conditions: Certain medical conditions increase the risk of acid reflux. These include scleroderma, eosinophilic esophagitis, systemic sclerosis, hiatal hernia, oesophageal cancer, and oesophagitis. 

What are the symptoms of Acid Reflux?

The symptoms of acid reflux develop after a heavy meal, and most of the time, they occur at night. The common symptoms are;

Heartburn or acid indigestion: It is a discomforting and painful sensation that moves from the stomach towards the middle of the chest and abdomen. Sometimes, it moves into the throat, too. Its name is a misnomer, and the heart is not affected. A heartburn frequency of less than 2 means acid reflux and, more than 2 means GERD.

Regurgitation: Regurgitation is the sensation of acid backing up in the mouth or throat. It causes bitter and sour taste, and a person experiences wet burps and burning or discomfort in the throat or chest. 

Dyspepsia: It is a general term used to refer to the pain and discomfort in the upper abdomen. It causes symptoms like bloating, fullness, nausea after a meal and burping. 

Chest pain: The chest pain is felt as if in a heart attack. It is squeezing and sharp and radiates towards the back, arms and neck. Acid reflux and GERD are the most common causes of non-cardiac chest pain (NCCP), and 58% of patients reported it, according to a study by Anastasios Karlaftis and colleagues in 2013 (Athens Medical School, Greece) 

Dysphagia: It means difficulty in swallowing food and water. It occurs as the acid damages the oesophagus, causing inflammation, scarring and narrowing. The sensation of something stuck in the food pipe develops. The painful swallowing causes a loss of interest in food. The non-obstructive type of dysphagia is reported by 48% of patients with regurgitation and heartburn (Andrea Batista, Universidade de São Paulo).

Regurgitation of stomach contents into lungs: In severe and rare cases, the contents reach the lungs through the throat, causing a condition known as aspiration pneumonia. It results in high-grade fever, wheezing, bluishness of lips and skin and difficulty breathing. The acid irritates the vocal cords and throat, causing a chronic cough, sore throat and hoarseness.  Aspiration pneumonia accounts for 5-15% of all cases of pneumonia.  

Laryngitis: The acid irritates the larynx (voice box), leading to chronic laryngitis. It results in sore throat, hoarseness, irritated and dry throat, cough, attempts to clear throat, painful and difficult swallowing and loss of voice in severe cases. 

Hypersalivation: Some people experience increased saliva production in response to acid reflux. It occurs due to irritation of the oesophagus, activation of the swallowing reflex and hyperresponsiveness of the nervous centres that control saliva production. 

Nausea: In severe cases, nausea and vomiting are experienced. More than half (56.9%) of patients with chronic acid reflux, according to research published in 2022.

Oral signs: The acid reflux reaching the mouth causes the breakdown of tooth enamel, particularly on the inner side. It causes symptoms like redness of the palate, bad breath, burning and acidic sensation in the mouth and dry mouth. The sign of enamel erosion develops.

Symptoms in children: Vomiting or spitting food is common in babies. A high frequency of vomiting or spitting indicates acid reflux. The symptoms parents report are refusal to eat and drink, choking or gagging, troubled swallowing, hiccups or wet burps, back arching, irritability during or after the feeding, sleeping difficulties, pneumonia, recurrent cough, poor growth and weight loss. 

Emergency symptoms in children: Some symptoms of acid reflux are not actually due to acid reflux and indicate the presence of other health conditions. For example, the chest pain in acid reflux resembles that of a heart attack. The signs that need immediate attention are unexpected weight loss or poor weight gain as expected from age, having poor growth and less weight than normal, baby crying more than usual, difficulty while swallowing and breathing, signs of dehydration, projectile vomiting, vomiting large amounts of yellow or green bile or blood, rectal bleeding and blood in the stools. 

What is the Diagnosis of Acid Reflux?

The diagnosis starts with a physical examination. Based on the physical examination findings, the clinicians recommend different tests to confirm. 

Physical examination: The GP reviews the medical history and symptoms during the physical examination. The GP starts treatment without further testing if the typical symptoms are present. However, tests are needed if there are atypical symptoms like hypersalivation, chest pain, nausea, asthma signs, chronic cough and vomiting. The testing is recommended in severe types of acid reflux when damage to the oesophagus is suspected, the symptoms are refractory to the treatment or if the doctor is planning the anti-reflux surgery.

Upper endoscopy: In the upper endoscopy, the doctor examines the oesophagus, stomach and initial segment of the small intestine. It allows doctors to diagnose oesophagitis, acid-induced injury to the oesophagus and conditions like Barrett's oesophagus and oesophageal narrowing (strictures). Most people don't have diagnosable lesions in acid reflux, and only 10-15% show abnormal findings related to Barrett's oesophagus. The procedure is useful for diagnosing potential complications.

During the endoscopy, the doctors use an anaesthetic agent to control the gag reflex. Sometimes, only mild sedatives and painkillers are used. The patient is placed in the left lateral position (on the left side). Then, an endoscope is inserted from the mouth and pharynx towards the oesophagus. The endoscope pipe has a camera at the end, which catches images of the internal side of the stomach, oesophagus and duodenum; the image is displayed on the computer screen. The doctor interprets the images to find out the abnormalities.

pH monitoring: During pH monitoring, the doctors use a wireless pH testing device to monitor the reflex activity over a long time while the patient continues performing routine life activities. Two different methods of wireless pH testing are;

• Wireless pH monitoring (bravo test): It enables healthcare professionals to monitor the gastric pH over extended periods (at least 48 hours) during everyday activities. The doctor uses the endoscope to place a small chip or capsule in the lower part of the oesophagus. The chip has sensors that record the acid levels in the lower oesophagus for 48 hours. The information is relayed to a recording device normally worn on the belt. The duration and frequency of reflex activity and the percentage time with less than 4 pH are recorded. Medications like H2 blockers and proton pump inhibitors must be stopped at least 3 days before the test. 
• 24 Hours pH impedance: The pH impedance procedure monitors the pH level for a prolonged period. A flexible and thin catheter having acid-sensitive sensors is inserted into the oesophagus from the nose. The sensors are placed at different spots to monitor the pH and determine the flow of materials from the stomach into the oesophagus. The catheters stay at the place for 24 hours. The patient maintains a symptom diary in which the nature and timing of symptoms are recorded. The data from sensors and symptom diary is analysed to identify the reflux episodes.
• Understanding reflex activity by both methods enables healthcare professionals to correlate symptoms with the reflux findings. It is useful to prepare a treatment plan. 

Esophageal manometry: It evaluates the motility of the oesophagus. It is not routinely used for acid reflux. However, it allows the physicians to understand the cause of symptoms and rule out other related gastric conditions. It is performed before performing anti-reflux surgery. A pressure-sensitive catheter is inserted into the oesophagus. The sensors attached to the catheter evaluate the coordination and strength of contractions of the oesophageal muscles. It detects the functioning ability of the lower oesophageal sphincter. 

Barium oesophagus or barium contrast radiography: It uses X-rays to diagnose acid reflux and GERD. In contrast radiography, a contrast solution known as barium sulphate contrast medium is swallowed. The barium coats the gastrointestinal tract, allowing doctors to diagnose the abnormalities. The X-rays are focused on narrowing or strictures in the oesophagus. The radiographic method doesn't detect acid reflux but is used to detect injury and cancer in the oesophagus.

What to Avoid When Having an Acid Reflux?

Consuming certain foods and drinks and using some supplements and medications increase the risk and exacerbate the signs of acid reflux. Pinpointing the foods responsible for the condition is tricky, and the medical community still struggles to determine the reason. Despite lacking supporting evidence, healthcare professionals agree that avoiding these foods helps prevent acid reflux and general indigestion.

Fried and high-fat meals: The fatty foods exert lower pressure on the lower LES and increase the stomach retention time. According to research by Carmelo Cottone (National Health System, Belluno Italy) in 2021, fried foods were a major trigger in 52% of the patients with acid reflux and GERD. Some high-fat foods that must be avoided are whole milk, potato chips, French fries, deep-fried items like onion rings, cheese, butter, ice cream, high-fat cream, creamy dips and sauces, high-fat salad dressings and high-fat red meat cuts like prime rib and marbled sirloin.

Certain vegetables and fruits: The fruits and vegetables have enormous health benefits and are an essential part of the diet. However, some fruits and vegetables make the symptoms of acid reflux worse. These are onion, garlic, tomatoes, other tomato-based foods, and citrus fruits like lemon, grapefruit, lime, oranges, and pineapple. Leaving all vegetables and fruits is sometimes not feasible or desirable, and the patients must consult a dietician to identify an eating pattern to manage the symptoms. 

Spicy foods: Spicy foods cause burning and abdominal pain in patients with gastrointestinal disorders. The black pepper causes relaxation of the LES. Likewise, capsaicin in spicy foods irritates the oesophagus and causes acid reflux. According to research by Carmelo Cottone (National Health System, Belluno Italy) in 2021, fried foods were a major trigger in 62% of the patients with acid reflux and GERD. Some researchers have provided opposite results, but most approve that spicy foods are unsafe for people with acid reflux or GERD. 

Beverages: Several drinks and beverages that trigger or exacerbate the symptoms are tomato and citrus juices, carbonated beverages, coffee, tea and alcohol. Caffeine in the coffee is particularly dangerous as it relaxes the LES. There are individual-level differences. Addressing these differences is important to identify the drinks that are well tolerated.

Miscellaneous foods: The other foods associated with acid reflux to a lesser degree are spearmint, peppermint, chocolate and highly processed foods. Alcohol and caffeine in coffee and tea irritate the inner lining of the oesophagus and relax the LES. It causes increased stomach acid production, an important trigger for acid reflux. The chocolate contains theobromine, which has the same effect. 

Late-night meals and snacks: Even healthy foods become dangerous if consumed within 2 hours of going to bed. It is better to divide the foods into 4-5 smaller meals than 2-3 bigger meals. The last meal must be at least 3 hours before going to bed.

Medications and supplements: Some supplements and medications reduce the functioning of LES and cause symptoms of acid reflux. These are pain relievers like aspirin, antibiotics, nitrates, alpha-blockers, bisphosphonates, sleeping pills, theophylline, tricyclic antidepressants, and potassium and iron supplements. If any such drug or supplement is suspected to cause symptoms, it is beneficial to talk to the doctor for guidance. 

It must be remembered that individual triggers vary from person to person. Identifying the individual factors and observing how the body responds to certain foods is important. Consultation with a dietician and general practitioner is very useful.

What are Home Remedies for Acid Reflux?

The medications are used to treat established cases of acid reflux and GERD. Some proven home remedies are helpful in managing the symptoms. They are cheap, easy to practise, and not associated with side effects. Sometimes, home remedies are used to provide temporary relief until medical treatment is available. The home remedies worth trying are;

Maintaining ideal weight: Heartburn and GERD are experienced by everyone. However, the risk and prevalence are higher in overweight and obese people. Obesity increases the risk of reflux diseases by 1.5-2.0 folds (Howard Hampel MD. PhD, Annals of Internal Medicine). Excessive body fat puts pressure on the abdominal area and pushes the stomach contents upward. Managing weight and achieving a desired BMI of 18.5-24.9 through regular exercise and balanced diets is useful in reducing acid reflux. 

Identifying the responsible foods and drinks: Many foods and drinks trigger or increase the risk of developing acid reflux. Such foods cause worsening of symptoms in people already experiencing the condition. The foods to be avoided are tomato-based foods and sauces, fatty, greasy and fast foods, fried foods, citrus fruits, garlic, chocolate, caffeine, alcohol, mint and onions. The individual response varies from person to person, and a person must be aware of how his gut behaves. Maintaining a food journal is an important practice that helps to identify the triggering foods.

Improving dietary habits: Eating smaller meals and avoiding lying down immediately after meals are useful tips. Smaller meals reduce the pressure build-up inside the stomach. It helps in weight management by reducing caloric intake. Lying down immediately after a meal is dangerous as it causes gravity-facilitated movements of stomach contents into the oesophagus. The health professionals, e.g., Danisa M. Clarrett, MD and Professor Christine Hachem, MD, advise head elevation during sleep with a pillow to prevent nighttime heartburn.

Leaving smoking: Quitting smoking benefits smokers with acid reflux and GERD. Smoking damages the oesophageal sphincter and increases the acid production in the stomach. It results in more frequent heartburn and GERD. Exposure to secondhand smoke is dangerous, too.

Eating healthy foods: There is no magic food that helps in acid reflux. Nevertheless, some dietary changes are helpful. The American Academy of Family Physicians has recommended using high-protein and low-fat meals to manage the symptoms of acid reflux. High protein and fibre keep the stomach full. Some people find chewing a non-mint gum to be useful for acid reflux. It helps by increasing the production of saliva.

Herbal remedies: The response to the herbal remedies is individual-specific. The herbs worth trying are slippery elm, marshmallow, liquorice, chamomile, ginger and aloe vera. These herbs are available as teas, tinctures and as supplements. Their benefits are self-reported and anecdotal, and little scientific evidence is available. Sometimes, they interfere with a person's medication, and a person taking medications must consult the doctor before using herbs.

Leave tight-fitting clothes: Clothing is not a factor for normal people. It worsens the symptoms in people already having acid reflux. Tight-fitting clothes like a right waistband and belt increase the pressure in the stomach. A person experiencing heartburn and acid reflux must add looser clothes to the wardrobe.

Using relaxation techniques: Stress causes acid reflux, and the acid reflux is itself stressful. Learning the practices that improve the mind-body connection is helpful. These techniques help relax the muscles and improve muscle movement, which are the main culprits of acid reflux. Relaxation techniques like yoga promote relaxation. Other techniques like deep breathing and meditation lower stress levels, which is a major trigger of acid reflux.

Avoiding fast-paced walking and exercising after a meal: Vigorous exercises or even fast walking involves bending the body and unnecessary movements of the stomach contents. It facilitates the travel of stomach contents from the stomach into the oesophagus. Nothing more than a mild stroll is recommended after a meal. Ideally, no physical activity must be performed within 30-60 minutes after the meal.

Sleeping in an incline position: It is advised to keep the head 6-8 inches above the feet level during sleep. The use of bed raiders is a good option to achieve it. If the sleeping partner objects, try using a foamy wedge support for the head. Stacking the pillows to create a wedge is not recommended, as it doesn't provide uniform support to the body.

Eat gut-friendly foods: Many foods benefit the gut and help in acid reflux. Foods containing added sugars and fats are associated with an increased risk of acid reflux. The vegetables like cucumber, potatoes, leafy greens, cauliflower, asparagus, broccoli and beans are lower in fats and added sugars. The spices like cinnamon and turmeric must be used for flavouring. The foods like ketchup, lemon, spices and butter increase the risk of acid reflux and must be avoided.

Ginger has anti-inflammatory properties, and it has been used for decades to treat gastrointestinal disturbances like nausea and indigestion. It is a natural prokinetic, which means it stimulates the movement of food into the digestive system. Drinking ginger tea or adding ginger slices to the smoothies and recipes is useful. It, however, doesn't work for all, and some people experience worsening signs. It is best to have a trial before moving ahead.

Oatmeal is an excellent source of fibre. The fibre absorbs stomach acids and reduces the risk of acid reflux. Brown rice and whole grain bread are other useful options to add more fibre to the diet.

Healthy fats are essential for the body and can't be abandoned completely. The unsaturated and healthy fats from plant sources like sunflower, sesame, olive, flaxseed, avocado and walnuts are useful and pose a lower risk of acid reflux. Deep-fried foods like doughnuts and fries must be avoided. Non-acidic drinks that do not contain caffeine, artificial sweeteners and alcohol must be used. The sound options are vegetable juices like carrot juice, plant-based milks and herbal teas.

Egg white has more protein and less fat and is associated with a lower risk of acid reflux. The egg yolk is the opposite and triggers acid reflux. So, only egg white must be used. If a person likes meats, seafood and lean meats like fish, turkey and chicken are less likely to result in acid reflux. Eating them in poached, grilled, baked or broiled form is useful.

A fruit lover must use non-citrus fruits like pears, apples, bananas and melons as they are less likely to cause acid reflux. Replacing unhealthy snacks containing fats and sugar, like chocolate, with non-citrus fruits is helpful. Fruits are a rich source of fibre, create a sense of fullness, and absorb stomach acid. 

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What are the Treatments for Acid Reflux?

The acid reflux responds well to lifestyle changes and medications. In rare and more advanced cases, surgery is needed. Various options for the treatment of acid reflux are; 

Medications: Both over-the-counter and prescription drugs are used to treat acid reflux. If over-the-counter medicines don't work, the patient must consult the doctors to prescribe the medications. Often, a combination of different drugs is used. Various medications used to treat acid reflux are;

Surgical procedures

If medications and lifestyle modifications fail, the doctors have to resort to surgeries as a last resort. Sometimes, the patients opt for surgical options to avoid the long-term use of medications. They are not entirely safe and have more risk of complications than the other options. Different medical and surgical procedures used are;

What are the Risk Factors of Acid Reflux?

The acid reflux is experienced by most of the people in their life. However, having certain health conditions, exposure to some lifestyle risk factors and use of certain medications increase the risk. The significant risk factors are; 

Pregnancy: Acid reflux is prevalent in pregnant women. It is due to hormonal changes that influence the tone and contractions of stomach muscles, pressure exerted by the expanding uterus and other issues experienced in pregnancy like vomiting, nausea and weight gain. The prevalence of acid reflux in specific populations reaches as high as 80% in pregnant women. 

Obesity: Being overweight or obese increases the frequency and severity of acid reflux episodes. Obese people have a higher risk of developing complications like GERD. Abdominal fat puts pressure on all abdominal organs, including the stomach, and loosens the LES, which remains open even without food. Consequently, the prevalence of GERD is as high as 72% in obese people. 

Hiatal hernia: The diaphragm separates the chest from the abdomen. In a hiatal hernia, the upper part of the oesophagus protrudes above into the chest cavity. Due to pressure differences in the chest cavity, the protruded position pushes against LES, causing the upward movement of the stomach contents. The radiological and endoscopic studies have found that 50-90% of people with GERD have hiatal hernia. The symptoms continue to worsen as the hernia continues to grow. 

Gastroparesis: It means partial or complete paralysis of the stomach. In gastroparesis, the motility of the stomach muscles is reduced, and the gastric emptying time is increased up to 41% (Ronnie Fass, MD). The extended stay of food in the stomach causes more production of acid, and ample time causes more risk. As a result, more than 25% of people with gastroparesis experience acid reflux and GERD (Surgical Endoscopy, 2008).

Disorders of the connective tissues: Connective tissues hold different tissues and organs together. The inflammation of these tissues reduces the functions of the organs. The involvement of the stomach results in acid reflux. The primary connective tissue disease responsible for acid reflux is scleroderma. 

Use of certain medications: Some medications cause acid reflux and GERD by influencing the acid production and contractions of stomach muscles. The medications causing acid reflux as a side effect are calcium channel blockers used to treat hypertension, tricyclic antidepressants, asthma medications, benzodiazepines, iron supplements, antibiotics, osteoporosis medications and nonsteroidal anti-inflammatory drugs ibuprofen and paracetamol.

Smoking: Cigarette smoke has many chemicals that influence the contractions of stomach muscles. It has an astringent effect that lowers the product of saliva and mucus, the essential components of acid protection and digestion. Consequently, consuming more than 20 cigarettes per day increases the risk of acid reflux by 53% in men and 37% in women, according to Zongli Zheng, MD and colleagues (Karolinska Institutet, Stockholm, Sweden). 

Alcoholism and drinking coffee: Several studies have linked alcoholism to acid reflux and GERD. However, some other studies have not found any tangible link. The same is true for coffee. The issues are person-specific, with some people experiencing issues while others do not.

Late-night meals: Larger meals at night or even regular meals just before going to bed increase the risk of acid reflux. That's why gastroenterologists recommend that the last meal must be at least 3 hours before going to bed. 

Specific exercises: The exercises are advised due to their health benefits. However, not all activities are helpful. Exercising immediately after eating and lifting heavy weights increases the risk of developing acid reflux by causing unnecessary movements and contractions of stomach muscles. Such exercises facilitate the upward movement of stomach contents. Leaving exercises is risky, too, and causes an increased risk of acid reflux. It is better to find a healthy balance.

Miscellaneous risk factors: Other factors include eating spicy, sour, fried and fatty foods, excessively drinking grapefruit or orange juices, using tomato preservatives or raw tomatoes in foods and using carbonated beverages or chocolate snacks. The researchers have noted that ageing (being 50 or above), stress, irregular meals, gender (females have higher risk) and asthma are among the risk factors.

What are the Complications of Acid Reflux?

Many people ignore acid reflux as a widespread and self-resolving issue. However, continuously experiencing acid reflux and having exposure to many risk factors for a long time result in gastroesophageal reflux disease (GERD) and many more complications later on. The consequences of untreated acid reflux are; 

Gastroesophageal reflux disease (GERD): It is a chronic digestive disease in which a persistent and heavy backflow of stomach contents causes severe signs, e.g., discomfort, chest pain, regurgitation and heartburn. It develops due to constant exposure to the risk factors of acid reflux. According to Stephen Sweet (Oxford PharmaGenesis, Oxford, UK) and Christopher Winchester (University of Aberdeen, Aberdeen, UK), 10-20% of people in Europe experience GERD. Untreated GERD leads to further complications like Barrett's oesophagus, oesophagal strictures, oesophagitis, tooth decay, etc. 

Erosive oesophagitis: It develops when excessive backflow of the stomach acid and enzymes (particularly pepsin) causes necrosis of the internal lining of the oesophagus, causing ulcers and erosions. It is experienced by 1% of the population (Catiele Antunes, Johns Hopkins Hospital). The mild cases are asymptomatic. However, the severe cases cause signs like painful swallowing (odynophagia), difficulty swallowing (dysphagia), regurgitation and heartburn. The endoscopy is used for the evaluation of lesions. 

Barrett's oesophagus: In Barrett's oesophagus, the columnar epithelium that lines the distal oesophagus is replaced with metaplastic columnar epithelium. It results from chronic exposure to the stomach contents and is a risk factor for the development of oesophageal cancer. It causes no apparent signs, and only the nonspecific symptoms of GERD are noted. Diagnostic procedures like endoscopy reveal the condition. Barrett's oesophagus is developed by around 5% of patients with GERD, but less than 1% of patients with Barrett's oesophagus ultimately develop oesophageal cancer.

Esophageal strictures: The long-term exposure to the stomach contents and the resultant injuries causes scar formation in the local tissues. The scar is less functional tissue and causes oesophagal strictures, a condition in which the oesophagus becomes narrow. The swallowing of food and water becomes difficult and painful, causing dehydration and weight loss. Different procedures are used to stretch the oesophagus gently. It is infrequent and is experienced by just 1.1 people out of 10,000. 

Oesophageal ulcers: The exposure to the enzymes and acid causes the development of sores and ulcers in the oesophagus, causing chest pain, nausea and difficulty swallowing food. The researchers at the LSUHSC- Shreveport and Ochsner Multiorgan Transplant Center noted that 2-7% of patients with GERD develop oesophagal ulcers. A long course of medications is recommended to treat the oesophagal ulcers. 

Oesophagitis: The stomach acids and enzymes cause irritation and swelling of the oesophagus lining, a condition known as oesophagitis. It causes chronic pain and other signs of acid reflux.

Risk of oesophageal cancer: Having GERD for a long time, development of Barrett's oesophagus and having a family history of signs increases the risk of oesophageal cancer. The symptoms of oesophageal cancer are just like ordinary signs of acid reflux, like chest pain and difficulty swallowing. They are not noticeable until the advanced stages of cancer, when it becomes difficult to treat. It is infrequent and is experienced by less than 1% of patients.

Tooth decay: Severe acid reflux causes the backflow of acidic contents into the mouth. The acid destroys the tooth enamel, weakens the tooth, and results in the development of cavities. According to a clinical review by Roger J. Smales and John A. Kaidonis (The University of Adelaide, North Terrace, Adelaide, Australia), tooth decay is reported by 24% of patients with GERD. 

Respiratory complications: The stomach contents reaching the upper oesophagus and mouth sometimes make their way into the airways, causing respiratory issues like wheezing, exacerbation of asthma, cough and recurrent pneumonia. The lining of the airways is more delicate than the lining of the oesophagus, and the stomach contents cause more severe irritation and swelling. The entry of contents into the lungs causes aspiration pneumonia. 

Cough, laryngitis and hoarseness: Hoarseness develops when the stomach contents reach the upper airways and affect the vocal cords that produce voice. The irritation, inflammation and swelling of the airways causes the voice to become hoarse and speech to become uncomfortable and unclear. The reaching of stomach contents into the larynx causes irritation and inflammation. It results in a scratchy and sore throat, persistent cough and painful swallowing. Chronic cough due to reflux laryngitis becomes a constant nuisance. The cough becomes persistent and worsens with time, resulting in a poor quality of life.

Why Does Anxiety Contribute to Acid Reflux?

Anxiety and acid reflux have a complex psychological and physiological interplay. A group of researchers at Ghulam Muhammad Mahar Medical College and Hospital and Jinnah Postgraduate Medical Centre found that 41.4% of GERD patients experienced depression, 34.4% experienced anxiety, and 27.13% experienced both. Anxiety causes or exacerbates acid reflux for a variety of reasons, which the health professionals explain. These include; 

Stress response: The body responds to stress and anxiety by eliciting a fight or flight response. The levels of stress hormones rise. It causes the relaxation of LES, among the other answers. The relaxation of LES facilitates the backflow of stomach contents into the oesophagus. 

Disturbance of gut functions: Anxiety disturbs the sensitivity and motility of the digestive system. It slows down the digestion process and causes increased stomach retention time, which facilitates the development of acid reflux. 

Disturbed eating habits: Anxiety disturbs eating habits. Some people resort to irregular and larger meals, mainly containing comfort foods that are strongly associated with acid reflux. The anxiety sometimes results in rapid eating without proper chewing, which leads to acid reflux. 

More acid production: Anxiety and stress increase the acid production in the stomach. It results in more severity and frequency of the symptoms of acid reflux. 

Increased sense of awareness: Anxious people are hypersensitive to even mild symptoms and begin to interpret common symptoms as severe signs. It adds to the condition. 

Side effects of anxiety medications: The anxiety causes people to take antacids and painkillers more frequently and carelessly, which adds to acid reflux.  

Changed lifestyle choices: Anxiety influences the lifestyle by causing poor dietary decisions, alcoholism and smoking, which increase the risk of acid reflux. 

The acid reflux and related signs are included in the spectrum of broader symptoms of anxiety and stress. Lifestyle changes to reduce stress levels are helpful.

Why Is Lifestyle One of the Causes of Acid Reflux?

Different lifestyle factors have an essential role in the development and exacerbation of signs of acid reflux and associated complications like GERD. Some important lifestyle factors are; 

Dietary choices: Choosing high-fat, acidic and spicy foods causes the relaxation of LES and irritation of the oesophagus that exacerbates the signs of acid reflux. Likewise, carbonated beverages, caffeinated drinks and alcohol cause acid reflux by relaxing or weakening the LES and stimulating acid production in the stomach. 

Eating habits: Some poor eating habits become a part of the lifestyle and add to the risk. These include quick eating, eating larger meals, late-night eating shortly before going to bed, etc. These habits increase the pressure inside the stomach and facilitate the flow of stomach contents into the oesophagus. 

Obesity: Obesity is not a lifestyle factor, but it is a grave consequence of many lifestyle factors. The abdominal fat exerts pressure on the stomach and LES, causing acid reflux. 

Smoking: Excessive smoking promotes acid reflux by weakening the LES and lowering the body's ability to clear the stomach contents from the oesophagus. 

Sedentary lifestyle: A sedentary lifestyle leads to poor digestion and obesity, both of which are the independent risk factors of obesity. 

Choice of clothing: Wearing tight waistbands and belts exerts pressure on LES and stomach. It results in a higher risk of acid reflux. 

Sleeping positions: Some people sleep on the right side or back. It facilitates the movements of stomach contents into the oesophagus as compared to sleep on the left side.

Choice of drinks: Some people have a habit of drinking alcohol, caffeinated drinks and carbonated beverages, all of which fit poorly to their digestive health. 

Fasting and dieting: Both dieting and fasting (like crash dieting) disturb the functioning of the stomach and LES, causing acid reflux. 

In short, an extensive array of lifestyle factors is involved, and the management of acid reflux due to lifestyle factors needs a comprehensive review of different factors.

Can Acid Reflux Lead to Cancer?

Yes, untreated and poorly managed acid reflux is a potential cause of cancer. Chronic and severe acid reflux causes GERD, and untreated GERD leads to a condition known as Barrett's oesophagus. In Barrett's oesophagus, the pre-cancerous changes appear in the cells of the inner lining of the oesophagus. The change is the result of a protective response by the body to chronic exposure to the stomach contents. A small number of people with Barrett's oesophagus develop esophageal adenocarcinoma, a cancer with high mortality. It is a rare cancer, and according to Cancer Research UK, 9,300 new cases of oesophageal cancer were reported in the country in 2016-18. It is the 7th most crucial cause of cancer deaths, with over 8,000 annual deaths in 2017-19. 

An early diagnosis and treatment is necessary. The risk of such complications varies from person to person. The factors influencing the development of oesophageal adenocarcinoma are lifestyle factors, genetics and duration and severity of the acid reflux symptoms. It is strongly advised that people with severe and chronic acid reflux must seek regular examination of the oesophagus and follow the treatment and prevention plan to reduce the risk and go for treatment immediately once the cancer is diagnosed.

Do Hormonal Pills Cause Acid Reflux?

Yes, in some cases, hormonal contraceptives increase the risk of developing acid reflux and exacerbate the symptoms even though they are not the direct cause. Sherif Saleh and colleagues (MetroHealth Medical Center, Cleveland, Ohio, USA) have identified the use of combined hormonal pills as an independent risk factor for acid reflux. The factors related to hormonal pills that are associated with acid reflux are; 

Relaxation of LES: The hormonal pills containing oestrogen cause the relaxation of LES. It is the ring of muscles between the stomach and oesophagus that prevents backflow of stomach contents. The loss of functions of LES is the primary cause of acid reflux. 

Increases stomach retention time: The hormonal contraceptives influence the motility of the gastrointestinal system and cause delayed gastric emptying. Oestrogen lowers the motility of the digestive organs, according to the American Physiological Society Journal. It allows the stomach contents to spend more time in the stomach and increases the risk of developing acid reflux. 

Effects of hormonal changes: The hormonal contraceptives disturb the balance of oestrogen and progesterone. Such changes are expected for most people, but some people show hypersensitivity to these changes. The hormonal changes increase the risk of acid reflux by loosening the functions of LES and increasing the acid production in the stomach. 

It must be kept in mind that such signs are experienced by only a minority of people, and for most people, the hormonal pills are entirely safe. The side effects that do offer are easily manageable. The response varies from person to person and is dependent on the individual physiology and formulation of the pills. A person experiencing severe signs of acid reflux after taking hormonal contraceptives must consult a healthcare provider, as it is often a sign of some other health conditions.

Does Fasting Cause Acid Reflux?

Yes, although fasting is not a direct cause, it creates a favourable environment for the development of acid reflux. Fasting is performed as a religious obligation by Muslims in the month of Ramadan. Abdullah Bahamad and his colleagues (Faisal University, Al Ahsa, SAU) found that the heartburn score increased from 14.3 to 17.9. The regurgitation score was higher in Ramadan too. Several factors responsible are: 

Reduced production of saliva: An extended period of fasting, particularly without food and water, reduces the production of saliva. Saliva neutralises the stomach acids and protects the inner lining of the oesophageal by covering it. The loss of saliva production means the oesophagus is now exposed to the corrosive effects of the acidic contents. 

Changes in gastric emptying time: When a person undergoes fasting after a large meal, the gastric emptying time is increased. It allows more time for the contents to stay in the stomach and cause acid reflux. 

Acid production in the gut: The skipping of meals or fasting causes more acid production as the body anticipates foods and is not receiving them. The increased acid production causes more risk of acid reflux. Overeating after fasting: Some people try to compensate for the fasting by overeating when they do eat. Overeating puts additional pressure on the LES and causes more pressure inside the stomach. Both factors favour the development of acid reflux. 

Lifestyle changes: Fasting, particularly those associated with cultural and religious events like Ramadan fasting in Muslim culture, is related to different lifestyles and dietary changes that contribute to the development of acid reflux. These include eating spicy and fatty foods and eating late at night. 

It must be kept in mind that not everyone fasting experiences acid reflux, and it depends upon factors like fasting mechanism, overall health status and the composition of diets used for dieting. It is essential to use foods that have a lower risk of causing acid reflux, use smaller and more frequent meals for breakfast and drink adequate water to maintain saliva production to reduce the risk of developing acid reflux with fasting. In case acid reflux becomes a persistent problem during fasting, the person must consult a doctor or dietician.

Does Acid Reflux Mean Heart Problems?

No, although heart problems and acid reflux share many common signs, they are distinct conditions. Acid reflux is the backflow of stomach contents into the oesophagus. Heart problems include heart failure, cardiac arrhythmias, coronary artery disease, etc. Both have radiating chest pain, breath shortness, fatigue and lightheadedness as the ordinary signs. However, there are marked differences among them, e.g.,

Location of organs involved: Heart diseases involve the heart, and some conditions involve the blood vessels. The acid reflux, on the other hand, consists of the stomach and lower oesophagus. 

Symptoms: The symptoms of heart disease depend upon the condition but include chest discomfort (angina), swelling in the ankles and legs, irregular heartbeat, fatigue and breath shortness. The symptoms of acid reflux are more related to food and digestion, and rarely, the respiratory system is involved. The signs include chronic cough, difficulty in swallowing, sour taste, regurgitation of food and a burning sensation in the chest. 

Diagnosis: The diagnosis of heart disease needs stress testing, echocardiogram, electrocardiogram, cardiac catheterization, etc. For the diagnosis of acid reflux, the history of signs, pH monitoring and endoscopy are used. 

Treatment and prognosis: The treatment options for heart diseases include coronary artery bypass surgery, placement of the stent, angioplasty, medications and lifestyle modifications. The acid reflux is treated using lifestyle changes, medications and surgeries in rare cases. The prognosis of acid reflux is much better than heart disease, and it responds much faster to standard treatments. Acid reflux is hardly a killer disease.

Is Acid Reflux a Chronic Condition?

Yes, acid reflux sometimes becomes a chronic condition. It persists for a long time and occasionally lasts for the whole life of a person. One feature of chronic acid reflux disease is a recurrence of signs. Symptoms like regurgitation and heartburn occur again and again on an intermittent or regular basis. The factors responsible for the chronicity of acid reflux are;

Structural changes: Chronic acid reflux induces long-term structural changes in the oesophagus, like erosions of the inner lining, scar formation and the development of Barrett's oesophagus. Such issues take time to be resolved and are never healed in the presence of continuous exposure to the acidic contents.

The need for ongoing management: The medications, dietary changes and lifestyle modifications help control the symptoms but are not a lifelong solution. Constant surveillance is needed to keep the symptoms in check. 

Potential complications: Untreated and poorly managed acid reflux causes more severe and prolonged complications like oesophagitis, oesophageal cancer and ulcers. The management of these conditions needs long-term care. 

In short, the need for a personalised treatment and prevention plan for the long term makes it a long-term illness.