An Issue of the Heart... Or Stomach: What Causes Acid Reflux
"While the symptoms of heartburn are unpleasant, there are also serious potential medical complications associated with it."
Let's talk heartburn! Many people suffer from heartburn on a regular basis. Sometimes we know what triggers it, and other times it's a mystery. Today, Dr. Keller Wortham, MD, is discussing Gastroesophageal Reflux Disease (GERD) — what it is, what causes it, and what we can do to calm down the digestive system and get relief.
- 01:07: What is Heartburn?
- 03:24: Symptoms of Heartburn
- 04:33: What Causes GERD
- 09:26: Health Concerns Associated with Acid Reflux
- 11:36: Diagnosing GERD
- 12:30: Treating Acid Reflux
- 17:43: Wrap-Up
What is Heartburn
First of all, the term “heartburn” is a little bit of a misnomer. As many of you probably know already, it has nothing to do with your heart, although it does burn. The burn is due to stomach acid coming up and irritating the esophagus, and it’s commonly referred to as heartburn because esophagus that burns is usually substernal, meaning you feel the burning sensation behind the heart.
The medical term for heartburn is Gastroesophageal Reflux Disease, or GERD. That term tells us exactly what the condition is — it's acid refluxing up from the stomach into the esophagus, and causing discomfort. So, why does that happen?
Well, the stomach is a very acidic environment. It's got really high acidity from hydrochloric acid, and enzymes that are produced in the stomach that are meant to digest food. It has to be a harsh environment in order for the enzymes to function properly and break down all that food and digest it.
The esophagus, on the other hand, is a much more delicate environment and the lining of the esophagus does not react well to stomach acid. Luckily, there's a little muscle between the esophagus and the stomach called the lower esophageal sphincter, which clamps down to prevent acid from coming up from the stomach into the esophagus, and relaxes to allow food to travel down into the stomach when it needs to. If it's working properly, this muscle closes up tightly to keep acid from coming up, but then opens to allow food to get down and everything goes well. When that little muscle doesn't work properly, it allows acid into that sensitive esophageal area, and your esophagus gets aggravated, resulting in heartburn.
Symptoms of Heartburn
The main symptom, which we already talked about, is that burning sensation under the chest. But there are other symptoms that you can experience as well, such as a chest pain. One important caveat here — sometimes people can have heart attacks and think it's heartburn. So, if you have any questions about it, go to your doctor, get screened for heart disease, and a potential heart attack. That aside, you know if you get that dull burning sensation, then you can often attribute that to heartburn.
Another symptom is an acidic taste in your mouth. You might actually taste the acids coming out. You could also have difficulty swallowing because of something called a stricture, which occurs when the esophagus starts to scar and narrow down because of all that acidity. You might experience a lump in your throat as that acidity kind of causes muscle spasm up there, and you can often get a hoarse voice as your vocal cords get acid on them and become inflamed and irritated. So, those are just some of the symptoms you can experience from acid reflux, or GERD.
What Causes GERD
We already know that it occurs when the lower esophageal sphincter muscle relaxes and allows acid to come up into the esophagus. But there are some things that can cause that to happen.
Excess Weight and Pregnancy
Obesity puts pressure in the abdomen, which can pressurize the stomach and push things up, leading to problems with the esophageal sphincter. Pregnancy can do the same thing, for the same reason — just increased pressure in the abdomen.
Connective Tissue & Neurologic Disorders
There are certain connective tissue disorders which can cause the muscle to malfunction. There are also some neurologic symptoms that prevent the stomach from working the way it should — maybe it doesn't empty fast enough, which is called delayed gastric emptying. This can be due to severe diabetes or other neurologic problems. When this happens, food sits in the stomach for a really long time and doesn't move downstream like it's supposed to, and then acid starts refluxing up into your esophagus.
There are some lifestyle things that can cause that little muscle down to not work properly. One of the first things is smoking — smoking is terrible for the body in so many ways, but you can add this one to the list. Nicotine can cause that muscle to relax and let acid up into the esophagus.
Alcohol & Caffeine
Certain Eating Habits
Eating large meals, especially late at night, can lead to acid reflux. That's because a large meal is also going to put pressure on that sphincter and cause food to come up. Also when you eat late at night, you usually lie down shortly afterward. When you lie down, gravity is not in your favor — the contents of the stomach can more easily travel sideways instead of having to travel upwards. So, eating a big meal late at night is a sure-fire way to set you up for a potential acid reflux.
Grease can be stimulating to stomach acid production, and can cause the sphincter to relax. So a big fried greasy meal, or even something like a donut, is a very likely trigger.
Some medications can be irritating to the lining of the stomach and the esophagus. Aspirin is a big one. Advil is another one. These block the production in the body of certain protective substances and molecules that protect the lining of our digestive tract. So practice caution when taking these medications.
Sometimes that little muscle we’ve been discussing, the lower esophageal sphincter, gets bumped out of place, allowing part of the stomach to herniate up into the chest cavity. When this happens, the diaphragm can't do its job, the stomach pokes through, and the sphincter is not in the right place, so it's not getting the support it needs. And that hiatal hernia can lead you to have a lot more acid reflux.
What Causes a Hiatal Hernia
Anything that increases pressure in the stomach area can force the stomach upward, so that can be coughing, severe vomiting, or straining (whether that's weight lifting or trying to move a heavy object). So be careful with those kind of activities because generating that force within your body and your lower abdomen can force the stomach upward into the chest cavity. Again, excess weight and pregnancy can also lead to a hiatal hernia, since they increase pressure on the stomach.
Health Concerns Associated with Acid Reflux
Acid reflux is annoying and unpleasant, but there are also some serious health concerns that can come with acid reflux. One of them is a narrowing of the esophagus. If that narrowing becomes severe, you actually develop a stricture that prevents food from traveling down, or cause severe pain when you're eating. So, an esophageal stricture, or scarring of the esophagus from that acid, is one of the risk factors.
You can get an open sore on the fragile esophageal tissue from all that acid, also known as an ulcer. Ulcers are not only very painful, they can also put you at risk for a GI bleed. Any time your gastrointestinal system is bleeding, it can bleed a lot and really quickly because it's very rich in blood supply that helps transport all the nutrients from our gut. But if it bleeds out into your digestive tract, you can lose a lot of blood really quickly, and that can be a real problem.
Precancerous tissue is another problem that can occur. Essentially, the acid coming up again and again into the esophagus causes the esophagus to try to repair itself. It goes into overdrive to try to heal itself and renew that tissue down there. It's possible that the cells can start to warp into cells that are precancerous, and that could lead to esophageal cancer. Esophageal cancer is very invasive and it often can be very hard to operate on.
So, again, acid reflux, GERD, heartburn — whatever you want to call it, it's not just about an unpleasant burning symptom. There are some serious issues that can occur so if you're having some of those symptoms, go to your doctor and get evaluated, and then they can confirm the diagnosis.
Your doctor may first run some tests to make sure you’re not having a heart attack. Most of the time, that’s not what it is. And then, if you’re dealing with heartburn, they can go through some steps. For example, they can confirm by doing a couple studies like an endoscopy, which is a camera that looks at the esophagus, to make sure it looks healthy, sees how irritated it may be, and rules out any infection of the stomach, gastritis, or cancer lesions.
They can also do something called a barium swallow. For this test, you would swallow a chemical dye, and then the doctor can X-ray it on the way down to see whether it’s traveling as it should, whether there’s a stricture narrowing on the way down, or whether there's evidence of a hiatal hernia. So, those are some studies we can do to try to confirm the diagnosis.
Treating Acid Reflux
Most of the time, especially if the symptoms are mild, your doctor will just help you find some strategies to improve those symptoms. Lifestyle changes are the easiest to address first. Sometimes it's difficult for people to change their habits, but medically, it's the most efficient thing to target first. So this can include losing weight to reduce pressure on the stomach, and avoiding things like caffeine, alcohol, and cigarettes that are making the condition worse. It can also include being very cautious about eating late at night or going to sleep right after eating. All of these things can reduce the risk of acid coming up into your esophagus. If these measures don’t work, medication may be the next step.
There are a lot of over-the-counter things available, so you can go to your pharmacy right now if you're having symptoms. The most common remedy is TUMS. These are basically calcium carbonate, which neutralizes stomach acid, so they’re great for quick relief. If you don't have chronic acid reflux, pop a couple of TUMS and that should help.
However, it’s important to note that TUMS don't really help reduce acid enough to heal a really irritated esophagus. So, if your esophagus is really irritated from high levels of reflux, you might have to try something else, like an H2 blocker. PEPCID, another common remedy, is an H2 blocker. H2 blockers reduce the stimulation of acid production, which can help reduce the irritation of the lining of the stomach, and give it some time to heal.
If these don't work, then you can try the next category of medications, also known as PPIs or proton-pump inhibitors. This is a type of medication that helps block the acid pumps in your stomach, which secrete hydrochloric acid in order to digest food. Prilosec also known as Omeprazole, is an example of a PPI. If you have an issue with a bad esophageal ulcer or the tissues are really damaged, a PPI cna help.
Side Effects of PPI’s
Unfortunately, if you take proton-pump inhibitors long-term, they can have some side effects:
- By reducing the acidity in the stomach, you reduce the absorption of calcium. So, over long periods of time, you can reduce the absorption of calcium enough to reduce it in the bones, putting you at a higher risk of osteoporosis. So it’s better if you don’t have to take something like Prilosec for a long period of time.
- They can reduce the absorption of some important B vitamins, like B12, which needs an acidic environment and certain proteins in the stomach to get in. A B12 deficiency wreaks havoc on a lot of systems.
- Any time you're reducing stomach acid, that makes digestion harder. So, you might notice you start experiencing issues digesting certain meats or other foods.
If none of the above options are helping your acid reflux, and especially if you have a hiatal hernia, then you can resort to certain surgeries.
The purpose of surgery is to make that esophageal sphincter work better. It might involve helping reduce the hernia and get it back in place, or they can help seal it off using magnets so that it's tight enough to keep acid from going up, but will open enough with the force of food going down. Or they can do a more involved surgery where they take part of the stomach and loop it up like a donut around the esophageal sphincter, creating a cushion around it.
We hope this little chat on heartburn was helpful. Again, while the symptoms of heartburn are unpleasant, there are also serious potential medical complications associated with it. So, if you're experiencing those symptoms of acid coming up, try some of the steps we talked about: avoid caffeine and alcohol, and try not to eat big greasy meals, try not to go to sleep or lie down right after you eat.
If you still have questions, please feel free to write us, or if you’re concerned about your symptoms, go see your doctor.