Acid Reflux and GERD

Acid reflux is a common occurrence among adults and is exacerbated by the increased incidence of excess weight and obesity over the past few decades. Acid reflux is the movement of gastric juices from the stomach into the esophagus, which can be occasional, typically after a fatty, spicy, or particularly large meal. Acid reflux can also be chronic, in other words, patients experience it regularly over an extended period. We classify this as gastroesophageal reflux disease or GERD.

Why Does Reflux Occur?

At the bottom of the esophagus, we all have a one-way valve known as the lower esophageal sphincter or LES. This muscle remains shut, only relaxing when food and drink are consumed or if we need to belch or vomit. If there is any laxity in the LES or it ceases to work correctly, it can loosen and open, allowing stomach juices to push back into the esophagus. The primary root cause of this upward movement of acid is excess weight and obesity, which puts additional pressure on the abdomen, thus moving fluid upward.

Some patients have what is known as a hiatal hernia or enlargement of the hiatus – a gap in the diaphragm that allows the esophagus to pass through. Hiatal hernias are typically asymptomatic, and most patients are not screened for them. They are usually found incidentally during other procedures, especially those involving the stomach or esophagus. Hiatal hernias are most commonly found in patients with obesity and excess weight.

That said, not all patients with chronic acid reflux are obese. Some of us are genetically predisposed to having a weaker LES and thus experience reflux even at a lower weight.

How Do We Diagnose Acid Reflux?

There are several ways to determine the degree of acid reflux that a patient is experiencing. A complete medical history will be taken, indicating if further diagnostic testing is needed. The first-line diagnostic test is an upper GI endoscopy involving putting a long flexible tube down the esophagus to check for damage from gastric juices. Esophageal pH monitoring can also tell us more about the cause of reflux. These tests are usually sufficient to develop a treatment plan if necessary.

How to Treat Acid Reflux

Treating occasional acid reflux is straightforward, and patients can get antacids like Tums over the counter at their local druggist or grocery store. These tablets, often chewable or soluble, neutralize stomach acid. So, while reflux still occurs, the gastric juices have a more neutral pH and cause fewer symptoms, if any.

For patients with GERD, the most effective way to address the condition is through lifestyle change, including improved diet and exercise, ultimately leading to weight loss and reduced intra-abdominal pressure. However, most of us know that sustained weight loss is challenging, and most patients cannot maintain this new healthy lifestyle over the long term. While behavior modifications such as eating your last meal earlier in the day, sleeping with your upper body propped up, and avoiding certain foods can help with symptoms, they do not address the underlying problem.

PPIs

Eventually, antacids may not work well enough to give patients relief from their chronic acid reflux. At this point, many patients will start Proton Pump Inhibitors or PPIs. PPIs work differently from antacids. Rather than neutralizing the acid, they limit the production of stomach acid in the first place. While these drugs are now sold over-the-counter, they are not indicated for long-term use. Some patients rely on them as a long-term therapy, but they increase the risk of several concerns. Learn more about the considerations of long-term PPI use.

Surgery

When lifestyle and medical therapy have failed, patients have surgical options performed by gastroenterologists or general surgeons. The grandfather of surgical intervention for GERD is known as fundoplication. During this procedure, the upper portion of the stomach is wrapped around the lower portion of the esophagus to restore pressure to minimize reflux. Fundoplications come in different styles, including a full wrap known as a Nissan fundoplication and partial wraps known as Toupet and Dor. These minimally invasive procedures are very effective but come with lifestyle impediments, including difficulty belching (gas-bloat syndrome) and vomiting.

There’s also an implant-based device known as the LINX reflux management system. This device approximates a small, beaded bracelet with a magnetic clasp. It is about the diameter of a quarter and wraps around the lower esophageal sphincter to add pressure. Because of its flexibility, it eliminates some of the concerns surrounding gas-bloat syndrome or difficulties with vomiting. However, not all patients will be comfortable with or qualify for an implant.

The Next Steps

Suppose you are experiencing chronic acid reflux, an unexplained chronic cough, or other throat-related issues. In that case, we encourage you to schedule a consultation with Dr. Boger to be evaluated and understand more about your condition.