Life-style changes can be the simplest and most effective acid reflux treatment, combining several changes in habit, especially related to eating.
At night, when individuals are lying down, it is easier for reflux to occur because gravity is not opposing the reflux, as it does in the upright position during the day. In addition, the lack of an effect of gravity allows the refluxed liquid to travel further up the esophagus and remain in the esophagus longer. These problems can be helped by elevating the upper body in bed by putting blocks under the bed's feet at the head of the bed or by sleeping on a wedge. It is important that the upper body and not just the head be elevated.
Reflux also occurs less frequently when patients lie on their left rather than their right sides.
Changes in eating habits can be a very helpful acid reflux treatment. Reflux is often worse immediately following meals because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. A smaller meal results in lesser distention of the stomach and by bedtime, a smaller and earlier meal is more likely to have emptied from the stomach than a larger meal so reflux is less likely to occur when patients with GERD lie down.
Certain foods are known to reduce the pressure in the lower esophageal sphincter (LES) and thereby promote reflux. Foods should be avoided include: fatty foods, chocolate, peppermint, alcohol and caffeinated drinks. Spicy or acid-containing foods, like citrus juices, carbonated beverages, and tomato juice should also be avoided.
Smoking also reduces the pressure in the sphincter and causes reflux.
One novel acid reflux treatment is chewing gum. Chewing gum stimulates the production of more bicarbonate-containing saliva and increases the rate of swallowing. After the saliva is swallowed, it neutralizes acid in the esophagus. In effect, chewing gum exaggerates one of the normal processes that neutralizes acid in the esophagus. It is not clear, however, how effective chewing gum actually is in treating heartburn. Nevertheless, chewing gum after meals is certainly worth a try.
Despite the development of potent medications for acid reflux treatment, antacids remain most commonly used. Antacids neutralize the acid in the stomach so that there is no acid to reflux. The problem with antacids is that their action is brief. They are emptied from the empty stomach quickly, in less than an hour, and the acid then re-accumulates. The best way to take antacids, therefore, is approximately one hour after meals or just before the symptoms of reflux begin after a meal. Since the food from meals slows the emptying from the stomach, an antacid taken after a meal stays in the stomach longer and is effective longer. For the same reason, a second dose of antacids approximately two hours after a meal takes advantage of the continuing post-meal slower emptying of the stomach and replenishes the acid-neutralizing capacity within the stomach.
Antacids may be aluminum, magnesium, or calcium based. Calcium-based antacids are usually calcium carbonate, which stimulate the release of gastrin from the stomach and duodenum. Gastrin is the hormone that is primarily responsible for the stimulation of acid secretion by the stomach. Secretion of acid rebounds after the direct acid-neutralizing effect of the calcium carbonate is exhausted. The rebound is due to the release of gastrin, resulting in an overproduction of acid which seems counter-productive. For this reason calcium-containing antacids such as Tums and Rolaids are not recommended. The occasional use of these calcium carbonate-containing antacids, however, is not believed to be harmful. The advantages of calcium carbonate-containing antacids are their low cost , the calcium they add to the diet, and their convenience as compared to liquids.
Aluminum-containing antacids have a tendency to cause constipation, while magnesium-containing antacids tend to cause diarrhea. If diarrhea or constipation becomes a problem, it may be necessary to switch antacids or alternately use antacids containing aluminum and magnesium.
Although antacids can neutralize acid, they do so for only a short period of time. For substantial neutralization of acid throughout the day, antacids would need to be given frequently, at least every hour.
The first medication developed for more effective and convenient acid reflux treatment, was a histamine antagonist, specifically cimetidine (Tagamet). Histamine is an important chemical because it stimulates acid production by the stomach. Released within the wall of the stomach, histamine attaches to receptors (binders) on the stomach's acid-producing cells and stimulates the cells to produce acid. Histamine antagonists work by blocking the receptor for histamine and thereby preventing histamine from stimulating the acid-producing cells. Histamine antagonists are referred to as H2 antagonists because the specific receptor they block is the histamine type 2 receptor.
Because histamine is particularly important for the stimulation of acid after meals, H2 antagonists are best taken 30 minutes before meals. The reason for this timing is so that the H2 antagonists will be at peak levels in the body after the meal when the stomach is actively producing acid. H2 antagonists also can be taken at bedtime to suppress nighttime production of acid.
H2 antagonists are very good for relieving the symptoms of GERD, particularly heartburn. However, they are not very good for healing the inflammation (esophagitis) that may accompany GERD. In fact, they are used primarily for the treatment of heartburn in GERD that is not associated with inflammation or complications, such as erosions or ulcers, strictures, or Barrett's esophagus.
Four different H2 antagonists are available by prescription, including cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine, (Pepcid). All four are also available over-the-counter (OTC), without the need for a prescription. However, the OTC dosages are lower than those available by prescription.
A proton pump inhibitor (PPI) such as omeprazole (Prilosec) blocks the secretion of acid into the stomach by the acid-secreting cells. The advantage of a proton pump inhibitor over an H2 antagonist is that the PPI shuts off acid production more completely and for a longer period of time. Not only is the PPI good for treating the symptom of heartburn, but it also is good for protecting the esophagus from acid so that esophageal inflammation can heal.
PPIs are used when H2 antagonists do not relieve symptoms adequately or when complications such as ulcers, strictures, or Barrett's esophagus exist. Five different PPIs are approved for the acid reflux treatment, including lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium). A fifth PPI product consists of a combination of omeprazole and sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken an hour before meals so it is at peak levels in the body after the meal when the acid is being made.
Recent guidelines indicate that PPIs should be the first drug treatment, given once a day for about 8 weeks. Even when symptoms are completely relieved by medication, they usually return within a few months after drug treatment has stopped. Long-term maintenance may be necessary.
Pro-motility drugs work by stimulating the muscles of the gastrointestinal tract, including the esophagus, stomach, small intestine, and/or colon. One pro-motility drug, metoclopramide (Reglan), is approved for acid reflux treatment. Pro-motility drugs increase the pressure in the lower esophageal sphincter and strengthen the contractions (peristalsis) of the esophagus. Both effects would be expected to reduce reflux of acid. However, these effects on the sphincter and esophagus are small so it is believed that the primary effect of metoclopramide may be to speed up emptying of the stomach, which should also reduce reflux.
Pro-motility drugs are most effective when taken 30 minutes before meals and again at bedtime. They are not very effective for treating either the symptoms or complications of GERD. Therefore, the pro-motility agents are reserved either for patients who do not respond to other treatments or are added to complement other treatments.
Foam barriers provide a unique form of treatment for GERD. Foam barriers are tablets that are composed of an antacid and a foaming agent. As the tablet disintegrates and reaches the stomach, it turns into foam that floats on the top of the liquid contents of the stomach. The foam forms a physical barrier to the reflux of liquid. At the same time, the antacid bound to the foam neutralizes acid that comes in contact with the foam. The tablets are best taken after meals (when the stomach is distended) and when lying down, both times when reflux is more likely to occur. Foam barriers are not often used as the first or only treatment for GERD. Rather, they are combined with other drug treatments when the other drugs are not sufficiently effective in relieving symptoms. There is only one foam barrier product available, which is a combination of aluminum hydroxide gel, magnesium trisilicate, and alginate (Gaviscon).
Sometimes acid reflux treatment with drugs is not effective. For example, despite adequate suppression of acid and relief from heartburn, regurgitation, with its potential for complications in the lungs, may still occur. Moreover, the amounts and/or numbers of drugs that are required for satisfactory treatment are sometimes so great that drug treatment is unreasonable. In these cases, surgery can effectively stop reflux.
The surgical procedure that is done to prevent reflux is technically known as fundoplication and is called reflux surgery or anti-reflux surgery. All of this surgery can be done through an incision in the abdomen (laparotomy) or using a technique called laparoscopy. During laparoscopy, a small viewing device and surgical instruments are passed through several small puncture sites in the abdomen. This technique avoids the need for a major abdominal incision and reduces recovery time and post operative pain.
During the fundoplication procedure, the part of the stomach that is closest to the entry of the esophagus (the fundus of the stomach) is gathered, wrapped, and sutured (sewn) around the lower end of the esophagus and the lower esophageal sphincter. (The gathering and suturing of one tissue to another is called plication.) This procedure increases the pressure at the lower end of the esophagus and thereby reduces acid reflux.
Also, during fundoplication, other surgical steps are often taken that may help reduce acid reflux. For instance, if the patient has a hiatal hernia (which occurs in 80% of patients with GERD), the hernial sac may be pulled down from the chest and sutured so that it remains within the abdomen. Additionally, the opening in the diaphragm through which the esophagus passes from the chest into the abdomen may also be tightened. Fundoplication may be done using a large incision (laparotomy or thoracotomy) or a laparoscope, which requires only several small punctures in the abdomen.
Surgery is very effective at relieving symptoms and treating the complications of GERD. Approximately 80% of patients will have good or excellent relief of their symptoms for 5 to 10 years. The most common complication of fundoplication is swallowed food that sticks at the artificial sphincter. Fortunately, the sticking usually is temporary. If it is not transient, endoscopic treatment to stretch (dilate) the artificial sphincter usually will relieve the problem. Only occasionally is it necessary to re-operate to revise the prior surgery.
Endoscopic techniques for acid reflux treatment have been recently developed and tested. One type of endoscopic procedure involves suturing (stitching) the area of the lower esophageal sphincter, which essentially tightens the sphincter.
A second type involves the application of radio-frequency waves to the lower part of the esophagus just above the sphincter. The waves cause damage to the tissue beneath the esophageal lining and a scar (fibrosis) forms. The scar shrinks and pulls on the surrounding tissue, thereby tightening the sphincter and the area above it.
A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. The injected material is intended to increase pressure in the LES and thereby prevent reflux. In one treatment the injected material was a polymer. Unfortunately, the injection of polymer led to serious complications, and the material for injection is no longer available. Another treatment involving injection of expandable pellets also was discontinued. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres.
Endoscopic treatment has the advantage of not requiring surgery. It can be performed without hospitalization. Experience with endoscopic techniques is limited. It is not clear how effective they are, especially long-term. Because the effectiveness and the full extent of potential complications of endoscopic techniques are not clear, it is felt generally that endoscopic treatment should only be done as part of experimental trials.
Transient LES relaxations appear to be the most common way in which acid reflux occurs. Although there are drugs available that prevent relaxations, they have too many side effects to be generally useful. Research is still underway for the development of drugs that prevent these relaxations without the accompanying side effects as a new acid reflux treatment.
By Mortin - Copyright 2009
Last modification 31/12/2009
Acid Reflux Treatment - References