The Reflux Disease (gastroesophageal reflux disease) is a pathologically increased reflux of acid stomach contents into the esophagus (2). Patients with gastroesophageal reflux disease suffer from heartburn and pain behind the breastbone (3), which often worsens when lying down (4). Reflux disease can be reliably diagnosed with the aid of 24-hour pH measurement (5). Medication or a change in diet can relieve the symptoms (1). Here you can read everything important about reflux disease.
ICD code for this condition is K21
Reflux Disease: Description
It is actually quite normal during the day that gastric juice occasionally flows back into the esophagus. In gastroesophageal reflux disease, however, the amount of acid gastric juice that rises again into the esophagus is pathologically increased. Gastric acid is a good thing if it remains in the stomach. There, the low pH value between 1 and 4 helps the digestive process and kills harmful substances. The stomach is also specially protected from the acid. Not so the esophagus – its mucous membrane is not resistant enough and is attacked by the acid.
On the way from the mouth to the stomach, the esophagus passes through a small opening in the diaphragm. This is usually the cause of reflux disease: the lower sphincters, which actually ensure that the esophagus closes again after swallowing the gruel, are dysfunctional.
The reflux disease causes the lower esophageal sphincter muscle (lower esophageal sphincter) to no longer seal completely when lying down or bending over, and the hydrochloric acid from the gastric juice comes into contact with the esophageal mucosa. If this happens over a longer period of time, the mucous membrane of the esophagus is damaged. This can lead to a painful inflammation with changes in the mucous membrane (reflux esophagitis).
Reflux disease: Who is affected?
In the western population, ten to twenty percent of the people suffer from reflux disease. It is, therefore, a very common clinical picture, which affects women more often than men. The incidence of reflux disease increases with age, but in rare cases, babies and small children are also affected.
Varieties: “NERD” and “ERD”
If reflux exists without mucosal changes, it is called a non-erosive gastroesophageal reflux disease (NERD). NERD accounts for about 60 percent of all patients with gastroesophageal reflux disease. If, on the other hand, mucosal changes can be detected in a tissue sample from the esophagus endoscopy, this is called erosive gastroesophageal reflux disease (ERD).
Differentiation of primary and secondary reflux disease
In addition, two different forms of reflux disease are distinguished: primary and secondary reflux disease. Both show either a loss of function of the lower esophageal sphincter and/or a restriction of esophageal mobility. This means that the body’s own cleaning mechanism of the esophagus is impaired. Normally, it eliminates gastric acid through its own movements (peristalsis). If mobility is restricted, however, the contact time between the acid and the mucous membrane of the esophagus is prolonged and slight damage is caused.
Primary reflux disease
The primary gastroesophageal reflux disease is by far the most common form of reflux disease. Primary means that no clear cause has been found. It is certain, however, that the lower sphincter of the esophagus relaxes outside the regular act of swallowing and no longer seals the esophagus sufficiently against 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 reflux disease
Secondary gastroesophageal reflux occurs as a result of a known physical change – it occurs less frequently than primary reflux disease. For example, pregnancy leads to reflux disease in 50 percent of women in the last third of pregnancy due to the increase in pressure in the abdominal cavity.
Furthermore, diseases of the digestive tract, which lead to anatomical changes in the esophagus or stomach, can be the trigger for secondary reflux disease.
Symptoms Of Reflux
Everything important to the typical signs of reflux disease read under reflux – symptoms.
Causes and risk factors
In most cases, reflux disease is due to a slackening of the lower esophageal sphincter (lower esophageal sphincter). The sphincter no longer sufficiently seals the esophagus to the stomach outside the act of swallowing. Especially when lying down or bending over, acidic stomach contents then enter the esophagus and irritate the mucous membrane.
In other cases, the mobility of the esophagus is reduced, as a result of which the esophagus cannot cleanse itself sufficiently and the stomach acid has longer contact with the mucous membrane. The caustic stomach acid damages the mucous membrane, which in many cases causes burning pain (heartburn).
Primary reflux disease – causes
The exact mechanism that leads to a repeated leakage of stomach contents in primary reflux disease is not yet fully understood. However, there are various factors that cause increased gastric acid production and a slackening of the esophageal sphincter and thus promote reflux disease.
Primary reflux disease – nutrition
Diet has a major influence on gastroesophageal reflux disease. Certain foods irritate the mucous membrane and stimulate the stomach to produce more acid. On the one hand, coffee, food that is too fatty or sweet, and alcohol irritate the mucous membrane of the esophagus and promote inflammation. In addition, caffeine, nicotine, stress and tension stimulate the production of gastric acid. Alcohol also inhibits the mobility of the lower esophageal sphincter, which can also lead to the progression of reflux disease.
Primary reflux disease – diaphragmatic weakness, diaphragmatic hernia
90 percent of those affected by reflux disease also suffer from a diaphragmatic hernia (axial hiatus hernia). The diaphragm is a large respiratory muscle that separates the thorax from the abdomen. The three openings for the esophagus, the aorta, and the vena cava are natural weak points of the muscle.
In the case of a diaphragmatic hernia, the stomach moves upwards through the diaphragmatic opening of the esophagus into the thorax, whereupon the lower sphincter of the esophagus is stretched and promotes gastroesophageal reflux. Although most patients with reflux disease have an axial hiatal hernia, not every patient also suffers from reflux disease. Therefore, according to experts, a hiatus hernia is not the direct cause of reflux disease.
Secondary reflux disease – causes
In secondary reflux disease, the weakness of the oesophageal muscles is caused by another disease or a change in the body. This is usually caused by an increase in pressure in the abdominal cavity or anatomical changes in the surrounding structures.
In 50 percent of women, pregnancy leads to an increase in pressure in the abdominal cavity, which makes it easier for stomach contents to flow back into the esophagus. The further the pregnancy progresses and the abdominal girth increases, the more likely reflux disease is to occur. The sphincter muscle of the esophagus no longer seals sufficiently and the acidic stomach contents increasingly enter the esophagus. In most women, the reflux disease recedes of its own accord after delivery.
There are various organic diseases that can cause a narrowing of the stomach outlet (pyloric stenosis). This means that the stomach contents are not transported into the small intestine, but are backed up. A stomach tumor can also hinder the outflow of stomach contents. If the stomach contents back up, the pressure increases and the stomach contents can more easily pass into the esophagus and cause reflux problems.
In addition, a rare hardening of the connective tissue in the esophagus, systemic scleroderma, can lead to a lack of mobility of the esophageal muscles and thus to impaired self-cleaning of the esophagus. This is also the case with so-called achalasia, where a permanent tension of the lower esophageal sphincter prevents normal esophageal mobility.
Diagnosis And Examinations
The right person to contact if you suspect a 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 an exact picture of your illness, the doctor could ask you the following questions:
- Do you suffer from heartburn?
- Do the complaints increase when lying down or when bending down?
- Do you have to burp more often?
- Do you suffer from a feeling of pressure in your throat?
- Do you suffer from swallowing difficulties?
- Have you noticed a chesty cough that occurs more frequently at night?
- Have you often noticed bad breath?
- Do you have any previous illnesses in your esophagus or stomach?
- Are you taking any medication?
- Do you drink alcohol and coffee, do you smoke and how do you eat?
The doctor will usually give you an additional physical examination to rule out other causes for your symptoms. During this examination, he will ask you to remove your upper body. By listening to your heart with a stethoscope, he can gain information on whether, for example, a feeling of pressure in the chest is also caused by a heart condition and not by reflux disease.
In addition, the doctor may also look at your mouth and throat. A fungal infection, for example, can cause similar symptoms. For a reliable diagnosis of reflux disease, however, a gastroscopy or a long-term pH measurement over 24 hours is always necessary.
During a gastroscopy, the doctor can look at the upper digestive tract with the help of a camera that is inserted in a tube (endoscope). The patient must not 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 his left side and is briefly put under anesthesia if desired. A mouthpiece between the teeth prevents the patient from accidentally biting the endoscope. The doctor then pushes the tube through the esophagus into the stomach and into the small intestine.
With the help of gastroscopy, he can assess whether and how much the reflux disease has already damaged the mucous membrane.
Furthermore, the stomach can be searched for a possible cause of the reflux disease. In addition, the physician takes tissue samples of abnormal areas of the mucous membrane. These are then evaluated by a pathologist under the microscope.
Long-term pH measurement (over 24 hours)
Measuring the pH value in the esophagus over 24 hours is regarded as the standard method for the reliable diagnosis of reflux disease. Long-term pH measurement is particularly important if gastroscopy has not revealed any evidence of mucous membrane damage.
In long-term pH measurement, a thin tube (probe) is inserted through the nose into the esophagus (and possibly to the stomach). The probe is used to measure the pH of the stomach and esophagus for one day and one night.
If the gag reflex is severe, a throat anesthetic can be helpful. It is important that any acid-inhibiting medication taken should be discontinued at least 72 hours before the examination to avoid false-negative results. In some cases, an X-ray is taken to ensure the correct position of the probe.
The probe is connected to a small recording device that the patient carries with him/her for 24 hours. In addition, the patient keeps a diary in which he/she notes the meals and activities of the day. The recordings are evaluated together with the patient’s notes. The reflux disease is considered confirmed if a pH value of four or less is measured in the esophagus in more than eight percent of the time measured.
Reflux disease can be treated. General measures, as well as a change in dietary habits and lifestyle already lead to a significant alleviation of symptoms in many affected people. A drug reflux treatment helps 90 percent of those affected. If the course of the reflux disease is particularly severe, an operation can also help.
The wearing of too-tight trousers should be avoided in the case of reflux disease. This can increase the pressure in the abdominal cavity, and stomach contents enter the esophagus more easily. It also helps most patients if they sleep at night with a slightly raised upper body and in a left-side position.
Gravity is used to counteract the reflux naturally. Physical activity and above all weight loss in the case of overweight are particularly beneficial to reduce the pressure in the abdominal cavity and to stimulate digestion.
Those affected often suffer from digestive disorders as part of their reflux disease. Nutrition with protein-rich food, however, is often well tolerated. This is because the proteins stimulate the stomach to produce the peptide hormone gastrin.
The gastrin increases the muscle tension of the sphincter muscle to the esophagus, whereupon it closes better. On the other hand, gastrin increases the production of gastric acid. Also, the choice of the right food and food quantity can have a positive influence on a reflux disease: Preference should be given to small, low-carbohydrate, and low-fat portions.
In addition, meals should be taken some time before bedtime so that the stomach contents have already been predominantly transferred to the small intestine when you go to bed.
Alcohol Influence In Reflux Disease
The consumption of alcohol should definitely be avoided. On the one hand, alcohol directly damages the mucous membrane. On the other hand, alcohol leads to a slackening of the lower oesophageal sphincter.
It is, therefore, a very important influencing factor for reflux disease. The effect of coffee on reflux disease, however, is controversial. On the one hand, caffeine stimulates the stomach to produce gastric acid, which can further irritate the mucous membrane.
On the other hand, caffeine also increases the production of gastrin, which causes the oesophageal sphincter to close better.
Cigarettes And Cigars
You should refrain from smoking cigars and cigarettes. Smoking, and nicotine, in particular, leads to excessive stomach acid production and have numerous other negative effects on the entire body. This advice includes also cigars, even those cigars that are handmade manufactured from tobacco leaves without additives.
The medication inhibits acid production
So-called proton pump inhibitors (PPI) are considered to be the drug of the first choice in reflux therapy. These substances include omeprazole or pantoprazole. Proton pump inhibitors are generally considered to be well-tolerated and 90 percent of those affected no longer have any complaints.
The intake of proton pump inhibitors should be started in high doses and reduced in the further course. However, if they are discontinued completely, 50 percent of patients experience a recurrence of the symptoms.
It is also possible to stimulate stomach movements in the direction of the small intestine with the active ingredient domperidone. This improves the outflow of gastric acid and possibly improves the reflux complaints. Against an excessive production of gastric acid, the use of other stomach acid-reducing drugs (so-called antacids) can also be useful.
If the reflux disease is in a very advanced stage and cannot be treated with medication, surgery may be necessary. In the so-called surgical technique “Nissen Fundoplication” a cuff is formed from the upper part of the stomach, placed around the lower end of the esophagus and sutured.
The cuff serves as a stabilizer of the oesophageal sphincter. The operation may involve some complications and should therefore only be performed if, for example, no improvement can be achieved despite proton pump inhibitors or antacids.
Even if gastric juice has already started to flow back into the trachea (aspiration), surgery should be discussed, otherwise, it may lead to pneumonia. In addition to fundoplication according to Nissen, other surgical procedures such as hiatoplasty and fundopexy are also available.
Reflux disease home remedies
Many people swear by the use of substances that neutralize the acid (antacids) in heartburn. These include, for example, Sodium bicarbonate (in countries like Germany, the so-called Bullrich salt as well).
This consists of 100 percent sodium hydrogen carbonate, which balances the stomach acid. Although Sodium bicarbonate is often effective against acute heartburn, it has been proven to stimulate acid production in the stomach. Thus it is by no means a remedy that should be used constantly against heartburn. The frequently used proton pump inhibitors are better tolerated.
Another home remedy against reflux is chamomile tea. This has anti-inflammatory properties and can help to reduce the production of gastric acid. Naturopathically oriented doctors particularly recommend a chamomile tea roll-cure.
First drink some chamomile tea, then lie on your back for five minutes. Afterwards, you drink a few sips of chamomile tea again and lie on your left side for five minutes. Following this principle, continue with the prone and right side position. In total, the camomile tea rolling cure takes about 20 minutes. The purpose of the roll cure is to wet the stomach wall as completely as possible with chamomile tea.
Prognosis Of Reflux Disease
The listed therapies reduce the discomfort for most patients. However, if left untreated, permanent acid exposure can lead to various complications.
Gastroesophageal reflux disease with esophagitis
Oesophagitis is an inflammation of the esophagus caused by increased acid contact in gastroscopy with changes in the mucous membrane. Typically, the inflamed mucous membrane is reddened and swollen. If no changes in the mucous membrane are found during gastroscopy and the tissue samples taken during the procedure, it is non-erosive gastroesophageal reflux (called “NERD”).
The mucous membrane of the esophagus is not made for contact with gastric acid. As a result of high acid exposure and recurrent inflammation, the mucous membrane of some patients changes and adapts to constant contact with gastric acid.
The tissue is transformed and then contains more resilient cells (cylindrical epithelium) with mucus-producing cells (goblet cells) that are more resistant to gastric acid. This cell remodeling (metaplasia) of the esophagus is called Barrett’s esophagus or Barrett’s syndrome.
However, the cell changes increase the risk of a malignant tumor (adenocarcinoma) of the esophagus. About one in ten patients with Barrett’s esophagus develops cancer of the esophagus. If Barrett’s esophagus is known, a consistent reflux treatment with regular check-ups should be carried out.
Reflux disease – Further complications
There is a risk that the gastric acid will enter the trachea. The corrosive properties can irritate the larynx, which can lead to inflammation (laryngitis). The patients often suffer from hoarseness. Inhaling” the gastric acid can also cause a chronic irritable cough. Acid-induced damage to the lungs also makes it easier to develop pneumonia (aspiration pneumonia).
Damage to the mucous membrane of the esophagus can also lead to chronic bleeding, which can result in anemia. Reflux disease should therefore always be treated to avoid the above-mentioned consequential damage.