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Reflux disease: causes and treatment

by Josephine Andrews
Published: Last Updated on 424 views

In reflux disease, some of the stomach acid flows back into the esophagus. Patients suffer from heartburn and pain behind the breastbone, which often worsens when lying down. Around 20 to 30 million Europeans are affected every day. Reflux disease can be determined with the help of a gastroscopy or a 24-hour pH measurement. Medication or a change in diet relieves the symptoms. Here you can read everything you need to know about reflux disease.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

K21

quick overview

  • Symptoms: heartburn, a feeling of pressure behind the breastbone, difficulty swallowing, bad breath when belching, damaged tooth enamel, dry cough and inflamed airways
  • Causes: Lower esophagus sphincter does not completely close the stomach, certain foods stimulate the production of gastric acid, diaphragmatic hernia, anatomical reasons, pregnancy, organic diseases
  • Diagnosis: Gastroscopy , long-term pH measurement over 24 hours
  • Therapy: No restrictive clothing, change your diet, avoid alcohol, take medication to prevent acid production, operations, home remedies such as chamomile tea
  • Prognosis: If left untreated and if there is prolonged acid exposure, inflammation of the esophagus, possible complications are a burned trachea, pneumonia, bleeding in the esophagus or esophageal cancer
  • Prevention: It is unclear whether and which changes in behavior will help in the long term or even prevent, individual trying out of various therapeutic measures (such as a change in diet) in order to identify possible influences

What are the symptoms of reflux?

In reflux disease, acidic gastric juice moves from the stomach into the esophagus. The lining of the esophagus, unlike the lining of the stomach, is not designed to come into contact with acid. Contact with the acid causes, among other things, a burning pain – the well-known heartburn.

heartburn

The typical reflux disease symptoms are heartburn and a feeling of pressure behind the breastbone. In most patients, the symptoms worsen when lying down or bending over. When the body changes position, gravity supports the unwanted backflow of stomach acid into the esophagus. The burning pain behind the breastbone is extremely uncomfortable and often worsens after large meals. Patients also complain of a salty or soapy taste in their mouth after eating.

feeling of pressure in the chest

Those affected often first attribute the reflux symptom of pressure pain in the chest area to the heart. The reflux symptoms are usually difficult to distinguish from an acute heart disease (heart attack) without further examination. Patients with a feeling of pressure in the chest should therefore always consult a doctor. In addition to chest pain, some patients also complain of back pain . Whether there is a connection between reflux disease and back pain has not yet been sufficiently clarified.

difficulties swallowing

The mucous membrane of the esophagus becomes inflamed much more easily due to the increased contact with acid in reflux disease. The irritated mucous membrane is a good breeding ground for bacteria, and food particles stick to it more easily. The irritation of the mucous membranes often leads to patients having difficulty swallowing (dysphagia). The contact of the food with the mucous membrane additionally affects the inflamed tissue and causes pain.

Patients often report the feeling of “having a lump in their throat”. Other sufferers experience a persistent feeling of dryness that persists even though they drink enough.

bad breath and belching

The permanent irritation of the esophageal mucosa means that bacteria and food residues settle more easily on the inflamed mucosa. The inflamed tissue forms a good breeding ground for bacteria. The germs produce substances that escape with the breath and cause bad breath (halitosis).

When food meets stomach acid and digestive enzymes in the stomach, gases are formed. This is completely normal, but particularly pronounced with increased stomach acid. In patients suffering from a weak lower esophageal sphincter, it is easier for gases to escape “up” towards the esophagus than to escape through the long intestine. As a result, patients with reflux symptoms often have acidic belching.

Damage to tooth enamel

Classic reflux symptoms are also acid stress on the teeth and the associated damage to the enamel. Enamel is normally the hardest and most robust substance in the body and protects teeth from external influences. If the acidic gastric juice even gets into the mouth when belching, it attacks the enamel of the teeth. As a rule, this is first noticeable in the tooth necks.

Cough and damaged airways

In some patients, stomach acid rises to the point where it enters the airways. This causes reflux symptoms, which are associated with damage to the airways and the resulting urge to cough. Those affected complain of a chronic dry cough, especially at night. The rising gastric acid may damage the larynx , causing laryngitis with hoarseness.

Symptoms in Babies and Young Children

Reflux symptoms are already possible in infancy. However, the symptoms express themselves differently than in an adult: the children have problems with eating when breastfeeding or drinking. They behave restlessly and scream more and more. Some babies stretch their head and upper body backwards to make it easier for them to eat. Other children vomit more often after eating.

Since children of this age are not able to express their complaints, a careful eye on the part of the parents is required. Since persistent low food intake affects growth and development, early treatment of reflux symptoms in children is very important.

Recognizing reflux symptoms

The symptoms of reflux disease are usually easy to recognize. Nevertheless, reflux is still not always treated today, as those affected often trivialize the symptoms. If patients take reflux disease seriously and treat it, complications are usually avoidable. The differentiation of reflux symptoms from other causes such as heart disease, however, is only possible by a doctor.

What are the causes and risk factors?

In most cases, reflux disease is due to a relaxation of the lower esophageal sphincter (lower esophageal sphincter). The sphincter no longer adequately seals the esophagus from the stomach outside of the act of swallowing. In other cases, the esophagus is restricted in its mobility, which means that it is not able to clean itself sufficiently. The stomach acid therefore has longer contact with the mucous membrane.

There is a primary and a secondary form of the disease.

Causes of primary reflux disease

The exact mechanism that leads to the repeated leakage of gastric contents in primary reflux disease has not yet been fully elucidated. However, there are various factors that cause increased gastric acid production and relaxation of the esophageal sphincter, thus promoting reflux disease.

Influence of diet on the primary form

Diet has a major impact on gastroesophageal reflux disease. Certain foods irritate the mucous membrane and stimulate the stomach to produce more acid. On the one hand, coffee, foods that are too fatty or too sweet, and alcohol irritate the mucous membrane of the esophagus and promote inflammation. Caffeine , nicotine, stress and tension also stimulate gastric acid production. Alcohol also inhibits mobility of the lower esophageal sphincter, thereby promoting the progression of reflux disease.

The role of the diaphragm and the angle of His in the primary form

90 percent of those affected by reflux disease also suffer from a diaphragmatic hernia (axial hiatal hernia). The diaphragm is a large breathing muscle that separates the chest from the abdomen. The three openings for the esophagus, the main artery (aorta) and the vena cava (vena cava) are natural weak points in the muscle. In a diaphragmatic hernia, the stomach pushes up through the diaphragmatic opening of the esophagus into the chest, causing the lower esophageal sphincter to stretch and promote gastroesophageal reflux. Although most reflux sufferers have an axial hiatal hernia, not every patient suffers from reflux disease. Therefore, according to experts, a hiatal hernia is not directly the cause of reflux disease.

Another factor that promotes reflux disease is an enlarged “His angle”. The His angle is the angle between where the esophagus enters the stomach and the top of the stomach. Normally it is around 50 to 60 degrees. If it is enlarged above 60 degrees, the gastric juice flows back into the esophagus more easily.

Causes of the secondary form

In secondary reflux disease, another disease or change in the body is causing the esophageal muscles to become weak. This is usually caused by an increase in pressure in the abdomen or anatomical changes in the surrounding structures.

pregnancy

In 50 percent of women, pregnancy causes the stomach contents to flow back into the esophagus more easily due to the increase in pressure in the abdomen. The further the pregnancy progresses and the abdominal circumference increases, the more likely it is that reflux disease will occur. The sphincter muscle of the esophagus no longer seals properly, and the acidic stomach contents increasingly get into the esophagus. In most women, acid reflux resolves on its own after childbirth.

organic diseases

There are various organic diseases that promote a narrowing of the stomach outlet (pyloric stenosis). Even with a gastric tumor in the appropriate location, the outflow of gastric contents may be restricted. The stomach contents then do not get into the small intestine , but build up back up. This increases the pressure, the stomach contents pass more easily into the esophagus and thus leads to reflux symptoms.

In addition, a rare hardening of the connective tissue in the esophagus, systemic scleroderma , leads to a lack of mobility of the esophageal muscles and thus to impaired self-cleaning of the esophagus. This impairs the ability of the esophagus to clean itself. This is also the case with so-called achalasia, in which normal mobility of the esophagus is not possible due to permanent tension in the lower esophageal sphincter.

What tests and diagnoses are there?

The right contact person if you suspect reflux disease is your family doctor or a specialist in internal medicine and gastroenterology. With a detailed description of your symptoms and any previous illnesses, you provide the doctor with important information about your current state of health ( anamnesis interview ). In order to get a precise picture of your illness, the doctor will ask you the following questions, among others:

  • Do you suffer from heartburn?
  • Does the pain worsen when lying down or bending over?
  • Do you have more burping?
  • Do you suffer from a feeling of pressure in your throat?
  • Do you have trouble swallowing?
  • Have you noticed a dry cough that occurs more often at night?
  • Have you noticed bad breath on you more often?
  • Do you have previous illnesses in the esophagus or stomach?
  • Do you take medicine?
  • Do you drink alcohol and coffee, do you smoke and what is your diet?

The doctor will usually also examine you physically to rule out other causes of your symptoms. By listening to the heart with a stethoscope, he can obtain possible clues as to whether, for example, a feeling of pressure in the chest is caused by a diseased heart and not by reflux disease. If the doctor suspects a heart disease, further examinations such as an electrocardiogram ( ECG) and blood tests are shown. In addition, a visual check of your mouth and throat is useful, for example to rule out a fungal infection. This sometimes causes similar symptoms. However, a gastroscopy or a long-term pH measurement over 24 hours is always necessary for a reliable diagnosis of reflux disease.

Gastroscopy (esophago-gastro-duodenography)

During a gastroscopy, the doctor checks the upper digestive tract using a camera that is stuck in a tube (endoscope). The person concerned is not allowed to eat or drink anything for six hours before the examination so that the examiner has a clear view of the tissue. The patient lies on the left side and receives a short-term anesthetic if desired. A mouthpiece between the teeth prevents the patient from accidentally biting the endoscope. The doctor pushes the tube through the esophagus into the stomach and into the small intestine. He checks whether and how much the reflux disease has already damaged the mucous membrane and looks for a cause of the reflux disease. The doctor also takes tissue samples from conspicuous mucosal areas. These are then evaluated under the microscope by a pathologist.

Long-term pH measurement (over 24 hours)

Measuring the pH value in the esophagus over 24 hours is the standard method for reliably diagnosing reflux disease. A long-term pH measurement is particularly important if the gastroscopy has not revealed any evidence of damage to the mucous membrane.

For long-term pH monitoring, the doctor pushes a thin tube (probe) through the nose into the esophagus (and possibly up to the stomach). The pH value is measured via the probeof the stomach and esophagus measured for one day and one night. Throat anesthesia is helpful if there is a strong urge to gag. It is important that any acid-inhibiting medication taken is discontinued at least 72 hours before the examination in order to avoid false negative results. In some cases, an X-ray helps to ensure the correct position of the probe. The probe is connected to a small recorder that the patient carries with them 24 hours a day. In addition, he keeps a diary in which he notes the meals and activities of the day. The doctor later evaluates the recordings along with the patient’s notes. Reflux disease is confirmed if the esophagus has a pH of four or less for more than eight percent of the time measured.

How is reflux disease treated?

Reflux disease is easily treatable. General measures such as a change in eating habits and lifestyle already lead to a significant alleviation of the symptoms in many of those affected. Drug reflux treatment helps 90 percent of those affected. In the case of a particularly severe course of the reflux disease, surgical measures are an option.

General Measures

Wearing tight clothing, especially on the abdomen, should be avoided with acid reflux disease. This may increase pressure on the stomach, making it easier for stomach contents to enter the esophagus. It also helps most patients if they sleep at night with their upper body slightly elevated and on their left side. Gravity helps to naturally counteract reflux. Physical activity and, above all, weight loss if you are overweight are particularly beneficial in reducing abdominal pressure and stimulating digestion.

Diet for reflux problems

Those affected often suffer from indigestion as part of their reflux disease. A diet high in protein, on the other hand, is often well tolerated. The proteins stimulate the stomach to produce the peptide hormone gastrin. On the one hand, gastrin increases the muscle tension of the sphincter muscle to the esophagus, so that it closes better again. On the other hand, gastrin increases gastric acid production. In addition to choosing the right food, the amount of food plays an important role: small, low-carbohydrate and low-fat portions are beneficial. At best, the last meal of the day should be eaten some time before going to sleep so that most of the stomach contents have already reached the small intestine by the time you go to bed.

Avoid harmful substances

The consumption of alcohol must be avoided at all costs. On the one hand, alcohol directly damages the mucous membrane, on the other hand it causes the lower esophageal sphincter to relax. It is therefore a very important influencing factor for reflux disease. However, the effect of coffee on reflux disease is controversial. On the one hand, caffeine stimulates the stomach to produce gastric acid, which may further irritate the mucous membrane. On the other hand, caffeine also increases the production of gastrin, which helps the esophageal sphincter to close better. Just try out how good and how much coffee you can tolerate. You should refrain from smoking. Nicotine in particular leads to excessive gastric acid production and numerous other negative effects throughout the body.

Drugs inhibit acid production

So-called proton pump inhibitors (PPI) are very often used as medication in reflux therapy. These substances include, for example, omeprazole or pantoprazole . Proton pump inhibitors are generally considered to be well tolerated and 90 percent of those affected no longer have any symptoms. Patients start therapy with higher doses of proton pump inhibitors, which they reduce over time. After complete discontinuation, however, 50 percent of patients experience renewed symptoms. There is debate as to whether long-term use of PPIs increases the risk of bone fractures. It is possible that these drugs contribute to pneumonia, but the data is not clear on this either.

There are also medications that are supposed to bind and neutralize stomach acid (antacids). Agents containing alginate form a viscous gel with gastric acid. This gel floats on the chyme and forms a protective layer between the contents of the stomach and the esophagus. The previous studies on alginates do not allow a final assessment of whether they reliably help against reflux. Furthermore, there is the possibility of promoting the stomach movements in the direction of the small intestine with the active ingredient domperidone. This allows the stomach acid to drain away better, which may reduce reflux symptoms.

Operational Opportunities

If the reflux disease is in a very advanced stage and cannot be treated with medication, surgery is an option. Surgical intervention is also indicated when gastric juice is already flowing back into the trachea (aspiration). If left untreated, this can lead to pneumonia. In the so-called surgical technique “ fundoplicationaccording to Nissen” a cuff is formed from the upper area of ​​the stomach, placed around the lower end of the esophagus and sewn up. The cuff serves as a stabilizer for the esophageal sphincter. Since this procedure involves some risks, it is very important that the patient is given detailed advice in order to carefully weigh up the benefits and risks. In addition to the Nissen fundoplication, other surgical procedures such as hiatoplasty and fundopexy are available.

home remedies

Many people swear by the use of acid-neutralizing substances (antacids) for heartburn. This includes, for example, the so-called Bullrich salt. This consists of 100 percent sodium bicarbonate, which balances the stomach acid. Although Bullrich salt often helps against acute heartburn, it has been proven that it really boosts acid production in the stomach. It is therefore not recommended for permanent use.

Another home remedy for acid reflux is chamomile tea. This has anti-inflammatory properties and may help reduce stomach acid production. Naturopathically oriented doctors recommend a chamomile tea roll cure in particular. The affected person first drinks some chamomile tea, then he lies on his back for five minutes. Then he takes a few more sips of chamomile tea and lies on his left side for five minutes. He proceeds according to this principle with the prone and right lateral position. Overall, the chamomile tea roll cure takes about 20 minutes. The purpose of this procedure is to wet the stomach wall as completely as possible with chamomile tea.

Home remedies have their limits. If the symptoms persist over a longer period of time, do not get better or even get worse, you should always consult a doctor.

Who is affected?

In the Western population, ten to twenty percent of people suffer from reflux disease. It is therefore a very common condition that affects women more often than men. The incidence of reflux disease increases with age, but in rare cases babies and young children are also affected.

What is reflux disease?

An occasional backflow of gastric juice into the esophagus during the day is actually quite normal. In gastroesophageal reflux disease (also abbreviated to GERD), the amount of acidic gastric juice that rises back up into the oesophagus, however, is pathologically increased. The term “gastroesophageal” indicates involvement of the stomach and esophagus. Stomach acid, with its low pH of between one and four, helps with the digestion process and kills harmful substances in the stomach. The stomach itself is specially protected from the acid, but not the esophagus.

Features of different forms of the disease

Distinction between NERD and ERD

If there is reflux without mucosal changes, it is referred to as non-erosive gastroesophageal reflux disease (NERD). NERD accounts for about 60 percent of all sufferers with gastroesophageal reflux disease. If, on the other hand, changes in the mucous membrane can be detected in a tissue sample from the esophagus, this is referred to as erosive reflux disease (ERD).

Distinction of the primary and secondary form

Both forms of the disease show a loss of function of the lower esophageal sphincter (esophageal sphincter) and/or restricted mobility of the esophagus. This means that the body’s natural cleaning mechanism of the esophagus is impaired. Normally, the esophagus eliminates stomach acid by its own movement (peristalsis). If mobility is restricted, the contact time of the acid with the esophageal mucosa is longer and damage occurs more easily.

Primary gastroesophageal reflux disease is by far the most common form of reflux disease. “Primary” means that no clear cause was found. What is certain, however, is that the lower sphincter muscle of the esophagus relaxes after swallowing and no longer adequately seals the esophagus from the stomach. There are various factors that favor the development of primary reflux disease. These include obesity, certain eating habits (see causes and risk factors), a weakening of the diaphragm or insufficient protective mechanisms of the esophagus (restricted movement or reduced saliva production).

Secondary gastroesophageal reflux develops as a result of a known physical change – it occurs less frequently than the primary reflux disease. Examples of this are pregnancy and the associated increase in pressure in the abdomen. In addition, diseases of the digestive tract that lead to anatomical changes in the esophagus or stomach are possible triggers for secondary reflux disease.

Course of the disease and prognosis

The listed therapies reduce the symptoms in most patients. If left untreated, various complications are possible due to the permanent acid load.

Gastroesophageal reflux disease with esophagitis

Esophagitis is an inflammation of the esophagus (oesophagus), triggered by increased contact with acid in the gastroscopy with changes in the mucous membrane. Typically, the inflamed mucosa is red and swollen. If no changes in the mucous membrane are found during a gastroscopy and the tissue samples taken, it is a case of non-erosive gastroesophageal reflux (NERD).

Barrett’s esophagus

As a result of high acid exposure and recurring inflammation, the mucous membrane of some patients changes and adapts to constant contact with stomach acid. The remodeling of the tissue creates more resilient cells (cylindrical epithelium) with mucus-producing cells (goblet cells) that are more resistant to stomach acid.

This cell remodeling (metaplasia) of the esophagus is known as Barrett’s esophagus or Barrett’s syndrome. However, the cell changes increase the risk of a malignant tumor (adenocarcinoma) of the esophagus. Approximately one in ten patients with Barrett’s esophagus develops esophageal cancer. If Barrett’s esophagus is known, consistent reflux treatment with regular check-ups is important.

More Complications

If the stomach acid repeatedly gets into the mouth area, the tooth enamel will be damaged in the long term. Because the body is unable to repair tooth enamel, the damage is irreversible. There is also a risk of stomach acid getting into the trachea. The caustic substance irritates the larynx, which can lead to inflammation (laryngitis). Many patients suffer from hoarseness.

“Inhaling” the stomach acid also often causes a chronic dry cough. Acid-related damage to the lungs also makes it easier to develop pneumonia (aspiration pneumonia), since the damaged tissue is a good breeding ground for bacteria. Aspiration pneumonia is a very serious complication that can be life-threatening. Damage to the mucous membrane of the esophagus can lead to chronic bleeding and, as a result, to anemia.

Reflux disease should therefore always be treated to avoid consequential damage.

Prevent

Anyone who suffers from reflux would like to do something to prevent it themselves. However, it has not been sufficiently investigated whether behavioral changes help or prevent in the long term. Still, it’s worth a try. This allows you to try out whether certain foods such as coffee, spicy or greasy food, citrus fruits, carbonated drinks or large portions of food trigger the symptoms or have no effect. There is no guarantee that changing your diet or losing weight will make the symptoms go away.

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