High stomach acid
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, some people are more sensitive to the stomach acid. Some people develop symptoms with only a small amount of reflux, while others have a lot of reflux without developing oesophagitis or 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.
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 are often worse after a meal.
Some uncommon symptoms: if any of these symptoms occur it can make the diagnosis difficult as these symptoms can mimic other conditions. A persistent cough, particularly at night sometimes occurs. This is due to the refluxed acid irritating the trachea (windpipe). Asthma symptoms including coughing and wheezing can sometimes be due to acid reflux. Gum problems, bad breath, sore throat, hoarseness, and a feeling of a lump in the throat could all be possible.
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. Acid reflux often occurs if you have a hiatus hernia (when part of the stomach protrudes into the chest through the diaphragm). Regular heartburn is also more common in smokers, pregnant women, the overweight, heavy drinkers and those aged between 35 and 64. It can also occur after a heavy meal or when bending forward.
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.
What can I do to help with symptoms?
There has been little research to prove how well these 'lifestyle' changes help to ease reflux, but these are common suggestions:
Stop smoking - the chemicals from cigarettes relax the sphincter muscle and make acid reflux more likely.
Dietary recommendations - it is thought that some foods may relax the sphincter and allow more acid to reflux. Foods and drinks that have been suspected of making symptoms worse in some people include: peppermint, tomatoes, citrus, vinegar, chocolate, spicy foods, hot drinks, coffee, and alcoholic drinks. Drinking fennel, peppermint and chamomile teas after meals may help. Also, avoiding large volume meals may help. You could try chewing gum for an hour after meals
Drugs - 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), though other 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 available to buy from your local pharmacy or supermarket. 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. 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.
High acid levels
The stomach produces too much acid usually in response to stress or high consumption of caffeine, alcohol or sugar. Obesity can also be a contributory factor, as can overeating. Antacids provide temporary relief by neutralising stomach acid but the body reacts by producing even more.