Acid Reflux & Oesophagitis

Understanding the Oesophagus and Stomach

When we eat, food passes down the oesophagus (gullet) into the stomach. Cells in the lining of the stomach make acid and other chemicals which help to digest food. Stomach cells also make mucus which protects them from damage from the acid. The cells lining the oesophagus are different and have little protection from acid.

There is a circular band of muscle (a 'sphincter') at the junction between the oesophagus and stomach. This relaxes to allow food down, but then normally tightens up and stops food and acid leaking back up (refluxing) into the oesophagus. In effect, the sphincter acts like a valve.

What are Reflux and Oesophagitis?

* Acid reflux is when some acid leaks up (refluxes) into the 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. However, some people have a lot of reflux without developing oesophagitis or symptoms.

Gastro-oesophageal reflux disease (GORD)

This is a general term which describes the range of situations - acid reflux, with or without oesophagitis and symptoms.

What are The Symptoms of Acid Reflux and Oesophagitis?

* Heartburn is the main symptom. This is a burning feeling which rises from the upper abdomen or lower chest up towards the neck. (It is confusing as it has nothing to do with the heart!)

* Other common symptoms include: pain in the upper abdomen and chest, feeling sick, an acid taste in the mouth, bloating, belching, 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 may occur. If any of these symptoms occur it 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 trachea (windpipe). Asthma symptoms of cough and wheeze can sometimes be due to acid 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).
  

What Causes Acid Reflux and Who Does It Affect?

The sphincter at the bottom of the oesophagus normally prevents acid reflux. Problems occur if the sphincter does not work very well. This is common, but in most cases it is not known why it does not work so well. In some cases the pressure in the stomach rises higher than the sphincter can withstand. For example, during pregnancy, after a large meal, or when bending forward. If you have a hiatus hernia (when part of the stomach protrudes into the chest through the diaphragm), you have an increased chance of developing reflux. (See separate leaflet called 'Hiatus Hernia'.)

Most people have heartburn at some time, perhaps after a large meal. However, about 1 in 3 adults have some heartburn every few days, and nearly 1 in 10 adults have 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, the overweight, and those aged between 35 and 64.

What Tests Might Be Done?

Tests are not usually necessary if you have typical symptoms. Many people are diagnosed with 'presumed acid reflux' when they have typical symptoms, and the symptoms are eased by treatment. Tests may be advised if symptoms: are severe, or do not improve with treatment, or are not typical of GORD.

* Endoscopy is the common test. This is where a thin, flexible telescope is passed down the oesophagus into the stomach. This allows a doctor or nurse to look inside. With oesophagitis, the lower part of the oesophagus looks red and inflamed. However, if it looks normal it does not rule out acid reflux. Some people are very sensitive to small amounts of acid, and can have symptoms with little or no inflammation to see. Two terms that are often used after an endoscopy are:

• Oesophagitis. This term is used when the oesophagus can be seen to be inflamed.
• Endoscopy-negative reflux disease. This term is used when someone has typical symptoms of reflux but endoscopy is normal.

* A test to check the acidity inside the oesophagus may be done if the diagnosis is not clear.

* Other tests such as heart tracings, chest X-ray, etc, may be done to rule out other conditions if the symptoms are not typical.

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 sphincter muscle and make acid reflux 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 drugs 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 an exhaustive list. Tell a doctor if you suspect that a drug 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 abdominal pressure.
  

What are the Treatments for Acid Reflux and Oesophagitis?

Antacids

These are alkali liquids or tablets that neutralise the 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 drugs

If you get symptoms frequently then see a doctor. An acid-suppressing drug will usually be advised. Two groups of acid-suppressing drugs 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. Proton pump inhibitors include: omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole. H2 blockers include: cimetidine, famotidine, nizatidine, and ranitidine.

In general, a proton pump inhibitor is used first as these drugs tend to work better than H2 blockers. A common initial plan is to take a full dose course of a proton pump inhibitor for a month or so. This often settles symptoms down and allows any inflammation in the 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 drug '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 drug 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 drugs

These are drugs 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 drug treatment is not working well or not wanted long-term.

Are There Any Complications from Oesophagitis?

* Stricture. If you have severe and long-standing inflammation it can cause scarring and narrowing (a stricture) of the lower 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 become 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.

References

• Dyspepsia - proven gastro-oesophageal reflux disease, Clinical Knowledge Summaries (June 2008)
• The management of dyspepsia in primary care, MeReC Briefing, No 32, 2006.
• Dyspepsia: Managing dyspepsia in adults in primary care, NICE Clinical Guideline (2004)

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Stress Causes Acid Reflux

According to a National Heartburn Alliance Survey, over 58 million Americans suffer acid reflux , with 90 percent saying that acid reflux impacts or changes their lives. They also say cost of their medication impedes their ability to treat their conditions.
Although it has not been proven scientifically, many people believe that stress is a major contributor to acid reflux disease. Physiologically, stress can cause the digestive system to come to a screeching halt. Under stress the body sends energy to the muscles, via the blood stream, to help the body cope with a stressful situation. This means that less blood, or energy, is flowing to the digestive system. When digestion is slowed down in this manner, undigested food and gastric juices remain in the stomach much longer enhancing the occurrence of acid reflux.

What is most striking about the results of this survey is that more than half of the respondents say they have a busy or stressful life which increases the onset and the severity of the symptoms of acid reflux. The study does point out that although there is no proven direct link between heartburn and stress, we do know that stress itself causes behavioral changes that contribute to the problem. Increases in smoking, alcohol use, fast food or eating late at night are just some of the few changes a person may undergo during stressful times.

Reducing Stress and Treating Acid Reflux Disease

Whether you suffer from chronic acid reflux and find that stress exacerbates the condition, or you experience occasional acid reflux brought on by bouts of stress, consider the following:

• Take the pressure off yourself - Lining up too many goals to be accomplished in too short a period of time can be very stressful. Do one thing at a time. Learn to relax and learn to say no when others become too demanding. Set your priorities straight and make lists that you can stick to. Go easy on yourself.

• Take your mind off of you - "Loosing your mind" is not the worst thing you can do. Meditation, Tai Chi, Hatha Yoga, Chi Gong and self-hypnotism are all great ways to relieve stress. Focusing on a demanding activity will take your mind off what is causing the stress. Not thinking about yourself can be very beneficial. These arts can also be applied to enhance life with positive improvement.

• Exercise your way to peace of mind - Everyone knows that exercise is essential for good health. Besides the physical benefits it is also an important way to relieve stress. Who has time to think about problems when you're about to win a tennis match! The endorphins produced in your brain while exercising create an opiate-like "good feeling" sensation that can take you far away from the cares of the day. It is important to find a way to make exercise fun, whether it be jogging with your dog or playing ball with your friends.

• "Let it be" - You cannot control everything in life. There will always be planes that are late arrivals or departures. The weather may not cooperate with that family picnic that you planned. Your mother-in-law may show up when least expected and there will always be taxes to pay. It is important to learn to roll with the punches. You can always find something good in an otherwise bad situation, but most importantly don't let it stress you out.

• Maintain an optimistic attitude - Never underestimate the power of positive thinking. Focus on the good things - not the bad things. Be excited about the future and believe that only good is in store for you. Better than projecting the future, concentrate on the present and demonstrate gratitude in the moment. Being optimistic not only affects others in a positive way, it gives you the balance that you need to be stress free.

• Have a good laugh! - Laughter is the great healer. A good laugh can relieve more stress than anything else. Watch a funny movie, go to a comedy club or go see Hunter Blue perform at Mimi's in New York City. Try to associate with people who make you laugh, or at least don't make you frown. Maintain a good sense of humor at all times. Stress cannot exist where there is laughter.

• Love a dog or a cat - Pet animals are a sure cure for stress. Their pure unaffected love and funny antics can blow that stress away. If you can't muster the obligation of responsibility for a pet, borrow someone else's pet or volunteer to be a care taker when they are out of town. Pets have a tranquilizing affect on us and their power to diminish stress should not be overlooked.

• Talk to a friend - It's very therapeutic when a trusted friend gives advice and thoughtful support. We all need objective guidance at times. Sympathy from friends and relatives has a calming affect and can reduce stress. It's almost as if you are not bearing your problems alone anymore and that kind of encouragement is invaluable.

• Get a massage - There is nothing quite as stress relieving as a good massage. I find that going for acupuncture is very relaxing as well. If you can't manage a massage, indulge in a long hot bath, whirlpool or steam shower.

It has been said that stress is a killer. Thankfully, its reduction is not rocket science and is quite easily accomplished. By reducing the stress in our lives, we can minimize the effect of the acid reflux condition. Of course there are other factors involved with acid reflux, but stress is certainly one of the big ones and should be dealt with in a serious manner. Relax!

© 2006 Wind Publishing
By Charles Stewart Richey

Stress Reduction

Relaxation training technique:
Record these directions for yourself by reading them slowly. Use the tape daily to practice the relaxation response:

Settle back as comfortably as you can and close your eyes. Let your self relax to the best of your ability. Now, as you relax like that, clench your right fist. Just clench your fist tighter and tighter and study the tension as you do so. Keep it clenched and feel the tension in your right fist, hand, forearm. Now relax. Let the fingers of your right hand become loose, and observe the contrast in your feelings. Now, let yourself go and try to become more relaxed all over. Once more, clench your right fist really tight Y hold it, and notice the tension again. Now let go, relax; your fingers straighten out and you notice the difference once more. Repeat that with your left fist. Clench your left fist while the rest of your body relaxes; clench that fist tighter and feel the tension. Now relax. Again, enjoy the contrast. Repeat that once more. Clench the left fist, tight and tense. Now do the opposite of tension: relax and feel the difference. Continue relaxing like that for a while. Clench both fists tighter and tighter, both fists tense, forearms tense. Study the sensations. Relax; straighten out your fingers and feel the relaxation. Continue relaxing your hands and forearms more and more.

Now bend your elbows and tense your biceps, tense them harder and study the tension feelings. All right. Straighten out your arms, let them relax and feel that difference again. Let the relaxation develop. Once more, tense your biceps; hold the tension and observe it carefully. Straighten the arms and relax; relax to the best of your ability. Each time, pay close attention to your feelings when you tense up and when you relax. Now straighten your arms. Straighten them so that you feel the most tension in the triceps muscles along the backs of your arms; stretch your arms and feel that tension. Now relax. Get your arms back into a comfortable position. Let the relaxation proceed on its own. The arms should feel comfortably heavy as you allow them to relax. Straighten the arms once more so that you feel the tension in the triceps muscles; straighten them. Feel that tension Y relax. Now concentrate on pure relaxation in the arms without any tension. Get your arms comfortable and let them relax further and further. Continue relaxing your arms even further. Even when your arms seem fully relaxed, try to go that extra bit further; try to achieve deeper and deeper levels of relaxation.

Let all your muscles go loose and heavy. Just settle back quietly and comfortably. Wrinkle up your forehead now; wrinkle it tighter. Now, stop wrinkling your forehead; relax and smooth it out. Picture the entire forehead and scalp becoming smoother as the relaxation increased. Now, frown and crease your brows and study the tension. Let go of the tension again. Smooth out the forehead once more. Now, close your eyes tighter and tighter. Feel the tension. Relax your eyes. Keep your eyes closed, gently and comfortably, and notice the relaxation. Now clench your jaws, bite your teeth together; study the tension throughout the jaws. Relax your jaws now. Let your lips part slightly. Appreciate the relaxation. Now press your tongue hard against the roof of your mouth. Look for the tension. All right. Let your tongue return to a comfortable and relaxed position. Now purse your lips. Press your lips together tighter and tighter. Relax the lips. Note the contrast between tension and relaxation. Feel the relaxation all over your face, all over your forehead and scalp, eyes, jaws, lips, tongue and throat. The relaxation progresses further and further.

Now attend to your neck muscles. Press your head back as far as it can go and feel the tension in the neck now roll it to the left. Straighten your head and bring it forward. Press your chin against your chest. Let your head return to a comfortable position and study the relaxation. Let the relaxation develop. Shrug your shoulders. Hold the tension. Drop your shoulders and feel the relaxation. Neck and shoulders relaxed. Shrug your shoulders again and move them around. Bring your shoulders up and forward and back. Feel the tension in your shoulders and in your upper back. Drop your shoulders once more and relax. Let the relaxation spread deep into the shoulders, right into your back muscles; relax your neck and throat, and your jaws and other facial areas as the pure relaxation takes over and grows deeper, deeper, ever deeper.

Relax your entire body to the best of your ability. Feel that comfortable heaviness that accompanies relaxation. Breathe easily and freely in and out. Notice how the relaxation increase as you exhale. As you breathe out, just feel that relaxation. Now breathe right in and fill your lungs inhale deeply and hold your breathe. Study the tension. Now exhale, let the walls of your chest grow loose and push the air out automatically. Continue relaxing and breathe freely, gently. Feel the relaxation and enjoy it. With the rest of your body as relaxed as possible, fill your lungs again. Breathe in deeply and hold it again. That's fine, breathe out and appreciate the relief. Just breathe normally. Continue relaxing your chest and let the relaxation spread to your back, shoulders, neck and arms. Merely let go. Enjoy the relaxation.

Now let's pay attention to your abdominal muscles; your stomach area. Tighten your stomach muscles, make your abdomen hard. Notice the tension. And relax. Let the muscles loosen and notice the contrast. Once more, press and tighten your stomach muscles, make your abdomen hard. Notice the tension. And relax. Let the muscles loosen and notice the contrast. Once more, press and tighten your stomach muscles. Hold the tension and study it, relax. Notice the general well being that comes with relaxing your stomach. Now draw your stomach in, pull the muscles in and feel the tension this way. Relax again, let your stomach out. Continue breathing normally and easily. Feel the gentle massaging action all over your chest and stomach. Now pull your stomach in again and hold the tension. Push out and tense like that; hold the tension. Once more, pull in and feel the tension.

Now relax your stomach fully. Let the tension dissolve as the relaxation grows deeper. Each time your breathe out, notice the rhythmic relaxation both in your lungs and in your stomach. Try and let go of all contractions anywhere in your body. Now direct your attention to your lower back. Arch your back, making your lower back quite hollow, and feel the tension along your spine. Settle down comfortably again, relaxing the lower back. Just arch your back and feel the tension as you do so. Try to keep the ready of your body as relaxed as possible. Try to localize the tension throughout your lower back area. Relax once more, relaxing further and further. Relax your lower back, relax your upper back. Spread the relaxation to your stomach, chest, shoulders, arms and facial area, these parts relaxing further, further, further, ever deeper.

Let go of all tensions and relax. Now flex your buttocks and thighs. Flex your thighs by pressing down your heels as hard as you can. Relax and note the difference. Straighten your knees and flex your thigh muscles again. Hold the tension. Relax your hips and thighs. Allow the relaxation to proceed on its own. Press your feet and toes downward, away from your face, so that your calf muscles become tense. Study the tension. Relax your feet and calves. This time, bend your feet toward your face so that you feel tension along your shins. Bring your toes right up. Relax again. Keep relaxing for a while.

Now let your self relax further all over. Relax your feet, ankles, calves and shins, knees, thighs, buttocks and hips. Feel the heaviness of your lower body as you relax still further. Now spread the relaxation to your stomach, waist, lower back. Let go more and more. Feel that relaxation all over. Let it proceed to your upper back, chest, shoulders and arms, right to the tips of your fingers. Keep relaxing more and more deeply. Make sure that no tension has crept into your throat; relax your neck and your jaws and all your facial muscles. Keep relaxing your whole body like that for a while. Let yourself relax all over.

Now you can become twice as relaxed as you are merely by taking in a deep breath and exhaling slowly. With your eyes closed you become less aware of objects and movements around you, thus preventing any surface tensions from developing. Breathe in deeply and feel yourself becoming heavier. Take in a long, deep breath and let it out very slowly. Feel how heavy and relaxed you have become.

In a state of perfect relaxation you should feel unwilling to move a single muscle in your body. Think about the effort that would be required to raise your right arm. As you think about raising your right arm, see if you can notice any tensions that might have crept into your shoulder and arm. You decide not to lift the arm but to continue relaxing. Observe the relief and the disappearance of tension.

Just carry on relaxing like that. When you wish to get up, count backward from four to one. You should then feel fine, refreshed, wide awake and calm.

Coping.org is a Public Service of James J. Messina, Ph.D. & Constance M. Messina, Ph.D., Email: jjmess@tampabay.rr.com ©1999-2007 James J. Messina, Ph.D. & Constance Messina, Ph.D. Note: Original materials on this site may be reproduced for your personal, educational, or noncommercial use as long as you credit the authors and website.

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