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Gastroesophageal reflux (heartburn) Causes, Symptoms and Treatment

The gastroesophageal refluxmeans the rise of part of the stomach contents into the esophagus (the tube connecting the mouth to the stomach). The stomach produces gastric juices, very acidic substances that help the digestion of food. However, the wall of the esophagus is not designed to resist the acidity of the contents of the stomach. Reflux causes inflammation of the esophagus, which results in burning and irritation. Over time, this can lead to damage to the esophagus. Note that a low level of reflux is normal and of no consequence, and one speaks then of physiological (normal) reflux.

In common parlance, heartburn is often referred to as gastroesophageal reflux.

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Causes of Gastroesophageal reflux (heartburn)

In most people with reflux, reflux is caused by poor functioning of the lower esophageal sphincter. This sphincter is a muscular ring located at the junction of the esophagus and stomach. Normally, it is tight, preventing the contents of the stomach from reaching the esophagus, opening only to let the food ingested and thereby acting as a protective valve.

In case of reflux, the sphincter opens at the wrong time and lets up the gastric juices of the stomach. People who suffer from reflux often have acid regurgitation after a meal or during the night. This phenomenon of regurgitation is very common in infants because their sphincter is immature.

Gastroesophageal reflux may also be related to hiatal hernia . In this case, the upper part of the stomach (located at the junction of the esophagus) “goes up” with the esophagus into the rib cage through the orifice of the diaphragm (the hiatal orifice).

However, hiatal hernia and gastroesophageal reflux are not synonymous, and hiatal hernia is not always associated with reflux.

Prevalence

In Canada, an estimated 10 to 30% of the population would be exposed by occasional episodes of reflux oesophagitis. And 4% of Canadians would have a daily reflux of 30% once a week (13).
An American study shows that 44% of people have gastroesophageal reflux at least once a month.
Regurgitations are extremely common in infants, but they are not consistently attributable to gastroesophageal reflux. Experts estimate that 25% of infants have real ebb. It peaks around the age of 4 months.

Evolution

In the majority of adults with the disease, reflux symptoms are chronic. The treatments most often offer complete relief, but temporary, symptoms. They do not cure the disease.

In infants, reflux usually disappears between 6 and 12 months of age as the child grows older.

Complications

Prolonged exposure of the esophagus to acidic gastric substances may cause:

  • Inflammation ( oesophagitis ), with more or less digestive lesions of the esophagus responsible for ulcers (or wounds) on the wall of the esophagus, which are graded in 4 stages, according to their number, depth, and extent ;
  • this inflammation or ulcer can cause hemorrhage  ;
  • narrowing of the diameter of the esophagus ( peptic stenosis ), which causes difficulty in swallowing and pain during swallowing;
  • Barrett’s esophagus . This is the replacement of the cells of the esophagus wall by cells that normally evolve in the intestine. This replacement is attributable to repeated “attacks” of stomach acid in the esophagus. It is not accompanied by any particular symptoms, but can be detected by endoscopy because the normal gray-pink color of the esophageal tissues takes on an inflamed pink salmon color. Barrett’s esophagus is at risk for ulcers and, most importantly, cancer of the esophagus.

Gastroesophageal reflux can also lead to distant complications:

  • a chronic cough,
  • a hoarseness of the voice
  • laryngospasm
  • oesophageal or laryngeal cancer in uncontrolled and uncontrolled reflux

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When to consult?

In each of the situations below, it is advisable to consult a doctor .

  • A burning sensation and acid regurgitation several times a week.
  • The symptoms of reflux disrupt sleep.
  • The symptoms come back quickly when you stop taking antacid medications.
  • The symptoms have lasted for over a year and have never been evaluated by a doctor.
  • There are alarming symptoms (see the symptoms part of heartburn ).

Symptoms of gastroesophageal reflux (heartburn)

Main symptoms

The main symptoms appear especially after meals or while lying down:

  • A burning sensation “going up” behind the sternum. Doctors talk about heartburn .
  • Acid regurgitation, which gives a bitter taste in the mouth.

Reflux may also result in less common and more general symptoms:

  • A hoarse voice, especially in the morning
  • A chronic sore throat
  • Asthma occurring at night and unrelated to an allergy.
  • Chronic cough or frequent hiccups
  • Nausea
  • Persistent bad breath
  • Dental problems (loss of tooth enamel)

In infants, the symptoms of reflux are as follows:

  • excessive regurgitation and / or vomiting;
  • pains, a refusal to drink, crying fits;
  • Stunting and anemia in severe cases.
  • Episodes of apnea (rare).

Alarming symptoms

Alarming symptoms lead to consult a doctor immediately as they may be signs of a complication or another disease.

  • Difficulty swallowing
  • Recurrent vomiting
  • Pain during swallowing
  • A cough, an asthmatic breath
  • A repeated need to rinse the throat.
  • Stomach upset
  • Abnormal weight loss
  • The appearance of blood in the sputum (sputum), or blood in the vomit or in the stool (black stools).
  • No improvement with medical treatment of 4 to 8 weeks.
  • Anemia (in case of significant blood loss)

The case of atypical symptoms

Good to know. The pain caused by reflux burn can sometimes be so intense as to suggest a heart attack. You need to see a doctor if you have unusual chest pain that radiates to the arm or jaw because it can really be a heart attack.

People at risk for Gastroesophageal reflux (heartburn)

  • People who have a hiatus hernia (see above).
  • Pregnant women during the last months of pregnancy. The fetus exerts additional pressure on the stomach, the reflux is in this case only temporary.
  • Obese or overweight people
  • People aged 50 and over. With age, some individuals have a less effective esophageal sphincter, which can cause gastroesophageal reflux.
  • People with scleroderma .
  • People practicing running or divers often have reflux during the effort

Risk factors

Smoking (cigarettes, cigars, and pipes) increases the risk of gastro-esophageal reflux. Stopping smoking, with other lifestyle measures, may help to reduce symptoms.

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Diagnosis of gastroesophageal reflux (heartburn)

In the presence of signs suggestive of reflux, the doctor may do what is called a “presumptive” diagnosis. He believes that this person probably has a reflux (without total certainty). Given the frequency of gastro-oesophageal reflux, this presumption authorizes the doctor to prescribe a “test treatment” by drugs, and diet and dietary instructions, hereinafter cited.

If there is no improvement in the symptoms under treatment, it may be something other than reflux. It is therefore important to see a gastroenterologist on the advice of the attending physician, for the realization of a “high endoscopy” or ”  Fibroscopy  ” after stopping treatment.

This allows you to see the lining of the esophagus and stomach and need to take samples. The specialist sometimes detects an “eosinophilic esophagitis”, inflammation of the esophagus not linked to reflux, but to a particular infiltration of white blood cells. Similarly, this examination can quickly detect, seeing them a “peptic esophagitis, stenosis, cancer or endobrachy esophagus.”

Often fibroscopy is normal, and does not confirm the “reflux”

The gastroesophageal reflux will be authenticated by an examination called pHmetry which quantifies the existence or not of reflux by 24 hours by measuring the degree of acidity of the esophagus. This examination involves introducing a probe, through the nose, into the esophagus. On the probe, sensors collect the pH of the esophagus, and can differentiate the pathological reflux, normal. It must be done 7 days after taking any proton pump inhibitor (PPI) type drug so that the results are not affected by the medication.

In case of persistence of symptoms in a person with a history of esophagitis or positive pHmetry without treatment, a “pH-impedancemetry” under treatment can be proposed, which allows to differentiate liquid, gaseous, acidic or nonacid reflux.

Finally, in order to be complete, it is possible to detect motor disorders of oesophageal conduction by the practice of a TOGD: oeso gastro duodenal transit. It allows visualizing the contours of the esophagus and its movements after ingestion of an opaque radio product. It can detect the contours of a hiatal hernia.
Other examinations, the manometry and the “high resolution manometry” make it possible to analyze, by sensors intra oesophageal, the motricity of the esophagus.

Some people have a functional disorder, a visceral hypersensitivity (the mucosa of their esophagus is sensitive): they find a normal endoscopy, a normal acid exposure (pHmetry), a total number of physiological reflux, normal, but a concordance between the symptoms and reflux under impedancemetry.

Prevention of gastroesophageal reflux (heartburn)

How to prevent gastro-oesophageal reflux?
Smoking and obesity contribute significantly to the onset of reflux. Not smoking and maintaining a healthy weight would therefore be means of prevention. But in the current state of knowledge, in most cases there does not seem to be any other way to prevent the onset of the disease.
Measures to reduce symptoms and prevent recurrence
Try to find out what the lifestyle is that alleviates your symptoms and discuss it with your doctor or nutritionist. These habits can vary from person to person. However, for the majority of people with reflux, it is easy to adopt the following good measures:

  • If you are overweight on the scale, try to lose a few pounds. Overweight and obesity are the main risk factors for reflux. Several studies have shown that voluntary weight loss can reduce symptoms in a sustainable way.
  • No study clearly shows the link between foods and worsening reflux. However, people with reflux often observe that certain foods make their symptoms worse, such as coffee, chocolate, fatty or spicy foods , soft drinks , citrus fruits (and their juices ), tomatoes, milk, and onions. Avoiding eating these foods can help reduce reflux.
  • Avoid eating peppermint and spearmint, which may affect the relaxation of the esophageal sphincter. Coffee would not be involved.
  • Avoid fatty and hearty meals. Some studies have pointed out those meals high in fat aggravated reflux, although this hypothesis remains controversial. In all cases, prefer light meals, but more frequent to facilitate the “emptying” of the stomach and avoid acid reflux.
  • Eat slowly: taking the time to chew food effectively does not overload the stomach.
  • Get out of satiated table but not “full stomach”
  • Avoid lying down after eating (wait two to three hours).
  • Avoid eating for three to four hours before bedtime.
  • For smokers … stop smoking! Tobacco slows the healing of oesophageal lesions and impairs the functioning of the sphincter.
  • Reduce your alcohol consumption. Alcohol increases acid secretion in the stomach and aggravates reflux. Above all, do not drink alcohol on an empty stomach.
  • Avoid tension and stress.
  • Avoid too tight clothing and belts, as they can exert pressure on the abdomen that may be strong enough for the lower esophageal sphincter to open, while it must remain closed.
  • Raise the head of the bed at least 15 cm (6 inches). If possible, place blocks of wood under the legs of the headboard or use a solid piece of foam under the mattress portion of the headrest (sleeping with a few extra pillows is not enough). This measure is effective in reducing night pain, but can be uncomfortable and disrupt sleep in some people.

Some medicines may cause reflux symptoms or help to irritate the esophagus: acetylsalicylic acid (aspirin) and other nonsteroidal anti-inflammatory drugs (ibuprofen), osteoporosis medications (Fosamax, calcium), antibiotics, menopausal hormone therapy, some sleeping pills … Supplements (iron, potassium) and herbs can also worsen the symptoms. Consult your doctor or your pharmacist.

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Medical treatment of gastroesophageal reflux (heartburn)

Pharmaceuticals

Whether you take a medicine against gastro-oesophageal reflux or not, it is essential to implement the measures to prevent recurrence listed above and to change certain lifestyle habits. If this is not enough, people with regular reflux can get a simple and effective treatment to relieve their symptoms. However, since reflux is a chronic disease , it is sometimes necessary to continue taking medication in the long term.

Several medications can be given to decrease gastric acidity:

  • The antacid (Maalox, Rocgel, Xolaam Rolaids, Tums) that neutralize stomach acid, to take in case of symptoms. If you have to use over-the-counter antacids for more than three weeks, it is necessary to consult your doctor;
  • the H2 antagonists (Tagamet, Raniplex, Nizaxid, Azantac, Axid, PEPCID, Zantac,) which reduce the production of acid by the stomach. H2 antagonists are available over-the-counter and usually sufficient to treat mild cases, in conjunction with the prevention tips described above. That said, it is not desirable to take antacids for long periods, as they may interfere with the absorption of certain nutrients;
  • The inhibitors of proton pump (PPI). If over-the-counter H2 antagonists or H2 antagonists do not completely relieve the symptoms, you should return to your doctor. He will prescribe PPIs (Inexium Lanzor , Pariet , Losec , Nexium , Pantoloc , Prevacid or their generics). These are the most effective medications for treating reflux, but they can cause side effects if they are not taken properly. It is therefore essential to follow the recommendations of your doctor. Depending on the age of the disorder, an endoscopy may be prescribed.

Moreover, in addition to medications, the doctor sometimes recommends excluding or limiting certain foods. See the Prevention section.

To remember :

30% to 40% of people with gastro-oesophageal reflux continue to have signs of reflux or to be embarrassed despite well-managed treatment. The majority of PPI-resistant reflux symptoms are secondary to “no pathological reflux”.

Good to know. A vitamin supplement is sometimes recommended by some specialists to people who are on anti-reflux medication to avoid certain deficiencies. According to some, a deficiency of vitamin B12, vitamin C, magnesium, possibly iron, can occur. Indeed, anti-reflux drugs can decrease the absorption of nutrients and some drugs. If you are taking another course, talk to your doctor or pharmacist.

Surgical treatment

In case of failure of drug treatments, surgery to treat gastroesophageal reflux is possible, but it is reserved for people with serious complications  such as (severe esophagitis not responding to treatment) related to a large Hernia Hiata . It is only very rarely practiced.

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