TRAFALGAR  PHARMACY

Acid Reflux and Oesophagitis

When acid from the stomach leaks up into the gullet (oesophagus), the condition is known as acid reflux. This may cause heartburn and other symptoms. A medicine which reduces the amount of acid made in your stomach is a common treatment and usually works well. Some people take short courses of medication when symptoms flare up. Some people need long-term daily medication to keep symptoms away.

What are reflux and oesophagitis?

• Acid reflux means that some acid leaks up (refluxes) into the gullet (oesophagus).
• Oesophagitis means inflammation of the lining of the oesophagus. Most cases of oesophagitis are due to reflux of stomach acid which irritates the inside lining of the oesophagus.

The lining of the oesophagus can cope with a certain amount of acid. However, it is more sensitive to acid in some people. Therefore, some people develop symptoms with only a small amount of reflux.

What are the symptoms of acid reflux and oesophagitis?

• Heartburn: this is the main symptom. This is a burning feeling which rises from the upper tummy (abdomen) or lower chest up towards the neck. (it actually has nothing to do with the heart)
• Other common symptoms: these include pain in the upper abdomen and chest, feeling sick, an acid taste in the mouth, bloating, belching, indigestion (dyspepsia), and a burning pain when you swallow hot drinks. Like heartburn, these symptoms tend to come and go, and tend to be worse after a meal.
• Some uncommon symptoms: these may occur and if they do, can make the diagnosis difficult, as these symptoms can mimic other conditions. For example:
  • A persistent cough, particularly at night sometimes occurs. This is due to the refluxed acid irritating the windpipe. Asthma symptoms of cough and wheeze can sometimes be due to acid leaking up (reflux).
  • Other mouth and throat symptoms sometimes occur such as gum problems, bad breath, sore throat, hoarseness, and a feeling of a lump in the throat.
  • Severe chest pain develops in some cases (and may be mistaken for a heart attack).

Who is affected by acid reflux?

Most people have heartburn at some time, perhaps after a large meal. However, about 1 adult in 3 has some heartburn every few days, and nearly 1 adult in 10 has heartburn at least once a day. In many cases it is mild and soon passes. However, it is quite common for symptoms to be frequent or severe enough to affect quality of life. Regular heartburn is more common in smokers, pregnant women, heavy drinkers, those who are overweight, and those aged between 35 and 64 years.

What can I do to help with symptoms?

The following are commonly advised. However, there has been little research to prove how well these lifestyle changes help to ease reflux:

• Smoking. The chemicals from cigarettes relax the circular band of muscle (sphincter) at the bottom of the gullet (oesophagus) and make acid leaking up (refluxing) more likely. Symptoms may ease if you are a smoker and stop smoking.
• Some foods and drinks may make reflux worse in some people. It is thought that some foods may relax the sphincter and allow more acid to reflux. It is difficult to be certain how much foods contribute. Let common sense be your guide. If it seems that a food is causing symptoms, then try avoiding it for a while to see if symptoms improve. Foods and drinks that have been suspected of making symptoms worse in some people include peppermint, tomatoes, chocolate, spicy foods, hot drinks, coffee, and alcoholic drinks. Also, avoiding large-volume meals may help.
• Some medicines may make symptoms worse. They may irritate the oesophagus or relax the sphincter muscle and make acid reflux more likely. The most common culprits are anti-inflammatory painkillers (such as ibuprofen or aspirin). Others include diazepam, theophylline, nitrates, and calcium-channel blockers such as nifedipine. But this is not a complete (exhaustive) list. Tell a doctor if you suspect that a medicine is causing the symptoms, or making symptoms worse.
• Weight. If you are overweight it puts extra pressure on the stomach and encourages acid reflux. Losing some weight may ease the symptoms.
• Posture. Lying down or bending forward a lot during the day encourages reflux. Sitting hunched or wearing tight belts may put extra pressure on the stomach which may make any reflux worse.
• Bedtime. If symptoms recur most nights, the following may help:
  • Go to bed with an empty, dry stomach. To do this, don't eat in the last three hours before bedtime, and don't drink in the last two hours before bedtime.
  • If you are able, try raising the head of the bed by 10-20 cms (for example, with books or bricks under the bed's legs). This helps gravity to keep acid from refluxing into the oesophagus. If you do this, do not use additional pillows, because this may increase tummy (abdominal) pressure.

What are the treatments for acid reflux and oesophagitis?

Antacids

Antacids are alkaline liquids or tablets that reduce the amount of acid. A dose usually gives quick relief. There are many brands which you can buy. You can also get some on prescription. You can use antacids 'as required' for mild or infrequent bouts of heartburn.

Acid-suppressing medicines

If you get symptoms frequently then see a doctor. An acid-suppressing medicine will usually be advised. Two groups of acid-suppressing medicines are available - proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). They work in different ways but both reduce (suppress) the amount of acid that the stomach makes. PPIs include omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole. H2 blockers include cimetidine, famotidine, nizatidine, and ranitidine.

In general, a PPI is used first, as these medicines tend to work better than H2 blockers. A common initial plan is to take a full-dose course of a PPI for a month or so. This often settles symptoms down and allows any inflammation in the gullet (oesophagus) to clear. After this, all that you may need is to go back to antacids 'as required' or to take a short course of an acid-suppressing medicine 'as required'.

However, some people need long-term daily acid-suppressing treatment. Without medication, their symptoms return quickly. Long-term treatment with an acid-suppressing medicine is thought to be safe, and side-effects are uncommon. The aim is to take a full-dose course for a month or so to settle symptoms. After this, it is common to 'step down' the dose to the lowest dose that prevents symptoms. However, the maximum full dose taken each day is needed by some people.

Prokinetic medicines

These are medicines that speed up the passage of food through the stomach. They include domperidone and metoclopramide. They are not commonly used but help in some cases, particularly if you have marked bloating or belching symptoms.

Surgery

An operation can 'tighten' the lower oesophagus to prevent acid leaking up from the stomach. It can be done by 'keyhole' surgery. In general, the success of surgery is no better than acid-suppressing medication. However, surgery may be an option for some people whose quality of life remains significantly affected by their condition and where treatment with medicines is not working well or not wanted long-term.

Another procedure being used involves placing a small magnetic device around the lower oesophagus. The device allows you to swallow but then tightens to stop acid reflux. Because there is not much research into this procedure, it is not often used in the UK at the moment.

Are there any complications from oesophagitis?

• Scarring and narrowing (stricture). If you have severe and long-standing inflammation it can cause a stricture of the lower gullet (oesophagus). This is uncommon.
• Barrett's oesophagus. In this condition the cells that line the lower oesophagus become changed. The changed cells are more prone than usual to becoming cancerous. (About 1 or 2 people in 100 with Barrett's oesophagus develop cancer of the oesophagus.)
• Cancer. Your risk of developing cancer of the oesophagus is slightly increased compared to the normal risk if you have long-term acid reflux.

It has to be stressed that most people with reflux do not develop any of these complications. Tell your doctor if you have pain or difficulty (food 'sticking') when you swallow, which may be the first symptom of a complication.