The symptoms that may signal acid reflux - and what you can do about it

If you have persistent heartburn or regurgitation, you may wind up in the exam room of a gastroenterologist such as Pooja Elias, M.D., being checked for acid reflux.

 

“Everybody refluxes,” she said. “It's a normal function for our GI tract. We have a valve at the bottom of the esophagus called the lower esophageal sphincter, or LES, and it's meant to relax when we swallow so food can move into the stomach. In that process, when the lower esophageal sphincter relaxes, sometimes gastric contents come back up.”

For most people, that’s fine. Even 50 reflux episodes in a 24-hour period is normal. “The difference is some people are doing that much more often or are more sensitive to the refluxate,” Elias said.

For them, stomach acid causes problems so often that it not only feels and tastes bad but also irritates the esophagus. Symptoms may include burping, feeling like something’s stuck in the throat, persistent hiccups, nausea, a dry cough and hoarseness.

Causes

Elias, a professor in the College of Medicine at the Medical University of South Carolina and part of the Digestive Services team at MUSC Health, said multiple factors can cause acid reflux. 

“Some people may have a laxity in their LES, making them more prone to refluxing. Others have a hiatal hernia, which is where part of the stomach moves above the diaphragm into the chest, making it very easy for acid to enter the esophagus.”

Other factors linked to acid reflux: being overweight or pregnant, having trouble emptying the stomach and suffering from a connective tissue disorder.

Treatments

Elias said both lifestyle changes and medications can reduce acid reflux.

• Empty the stomach

“I tell patients all the time, the best way to prevent reflux is to make sure that the stomach stays as empty as possible, especially in the evening. Not eating four hours before lying down is a great way to help keep the stomach empty,” Elias said.

Here’s why things may be different in the evenings for people with acid reflux. “During the daytime, your esophagus has the benefit of gravity helping it. When you're standing upright, reflux has to work against gravity and the propulsion of the esophagus, so everything tends to get pushed down – no harm, no foul.”

But if you’re lying down or your stomach is full, it can put a lot of pressure on the lower esophageal sphincter to stay closed. “The LES has to release; it's a valve, so it has to open when pressure builds up. And if you have stuff in your stomach, it all comes up into your esophagus.”

• Movement is medicine

The most important lifestyle change that may help: making sure there’s a big gap between dinner and reclining time. “I tell patients if you walk for 20 or 30 minutes after dinner, that is better than any medicine I'm going to be able to give to you because movement is medicine for the GI tract,” Elias said.

• Avoid trigger foods

Some acid reflux triggers are common. “I always list nine things. Fried, spicy, tomato-based, citrus, carbonation, chocolate, peppermint, alcohol, caffeine. All of those can be triggers for reflux,” Elias said. Other foods and drinks can trigger acid reflux, too. “Everybody's got specific triggers. So really minimize those. If you are going to eat them, eat them early in the day.”

• Medicine can help

While lifestyle changes are key, anti-acid medications can help in conjunction with them. Elias said proton pump inhibitors are one option. They cut down on how much acid the stomach makes by blocking an enzyme called the proton pump. Examples of proton pump inhibitors include Prilosec and Nexium. 

Another option: H2 blockers, the H referring to histamine. “They’re also acid suppression medications, but they work on different pumps in the stomach, and they work for a shorter period of time. So that includes medications like Pepcid and Tagamet.”

Elias said PPIs and H2s can be used together. “They work synergistically. So you can benefit from both if you need it.”

When you need more help

But some conditions that cause acid reflux can’t be solved with medication alone. “Some patients will have really big hiatal hernias, so half of their stomach is coming into the chest. No matter how much acid suppression we put them on, no matter how empty their stomach is, they're still going to constantly have that. And that's a whole different ballgame.”

So is Barrett’s esophagus. For people with that condition, acid reflux causes the lining of the esophagus to change. “It’s a precancerous condition. We really try to keep people from progressing because it can lead to esophageal cancer. But it’s rare, and we do a lot of things to prevent that.”

Elias said white men over 50 with longstanding reflux need to be screened for Barrett’s esophagus with an endoscopy. So do people with a history of family history of esophageal cancer.

But a small risk of developing cancer isn’t the only concern. Acid reflux can be a symptom linked to other problems with the esophagus, specifically its muscle function. “If someone is not benefiting from our measures at controlling acid, then we need to study their esophageal function. How does the esophagus squeeze? And does it squeeze in a coordinated way?” Elias said.

There are tests to determine that, along with other treatments, depending on what those tests find.

Bottom line

Elias hopes that talking about acid reflux raises awareness. “I want to make sure that people know that reflux does happen with everybody. But if they are able to keep their esophagus under less duress by walking after meals, not eating within four hours of bedtime and avoiding their trigger foods, this is a great start,” she said.

“If they're having symptoms, they should bring it up to their primary care doctor. They don't need to start on very high-dose medications right away. But with lifestyle changes and  low-dose acid suppression, we could control things. But if they're uncontrolled for four or six weeks, they should come to see a GI specialist so we can risk-stratify them and go from there.”