Dr Kevin McCarroll
Medical Matters
One of the most commonly prescribed medications in Ireland are proton pump inhibitors which are used in the treatment of acid reflux and peptic ulcers. In fact, up to 20% of adults suffer with gastro-oesophageal reflux disease (GORD) which appears to be increasing in prevalence and is more common in those of older age. GORD is commonly associated with lower quality of life, poor quality of sleep and decreased work productivity.
It occurs when acid from the stomach regurgitates back up into the gullet giving rise to a variety of symptoms. The commonest is the sensation of ‘heartburn’ but vague chest discomfort or crushing chest pain identical to angina may occur.
It can also present with a sore throat, hoarseness, a dry cough or sticking sensation (when swallowing) if acid reflux affects the vocal cords or pharynx.
There are several factors contributing to GORD including increased acidity of stomach contents and/or delayed gastric emptying. Weakness of the valve or sphincter that prevents acid regurgitating back into the gullet is also a common problem and can be due to a hiatus hernia. This results when there is herniation of part of the gullet (at the junction where it joins the stomach) up into the diaphragm and is not uncommon in older adults.
Pressure
Obesity is also associated with reflux as it can result in increased intra-abdominal pressure. Indeed, rising levels of obesity are believed to account for a significant proportion of the increase in new cases of GORD. Similarly, for this reason acid reflux is also very common in pregnancy though hormonal changes may also reduce the gastro-oesophageal sphincter tone.
So what can you do if you experience symptoms of acid reflux? Firstly, there are a number of lifestyle changes that can help and indeed in some cases, will be all that is required.
In particular, avoiding or cutting down on foods that may increase stomach acidity or reduce the lower oesophageal sphincter tone such as coffee, chocolate, citrus fruits, tomato products, spicy foods, and carbonated beverages may help. Fatty foods are harder to digest, tend to remain longer in the stomach and are also associated with heartburn.
Always avoid lying down, bending, stooping, going to bed or doing exercise soon after meals (within three hours) as this facilitates acid regurgitation. Drinking fluid at meals may in some cases promote reflux as can large meals.
Avoidance of smoking (which may reduce gullet sphincter competence) may also help. Importantly, if you are overweight then shedding some abdominal fat has been shown to improve reflux. It’s best also to avoiding wearing tight fitting clothes around the waist.
If your symptoms are bothersome at night or suggestive of acid reflux higher up in your throat, then sleeping with the head of the bed elevated may be useful.
When there are ongoing symptoms despite addressing lifestyle factors, then over-the-counter remedies or prescription medications will be required.
For occasional symptoms, over the counter antacids work well but their effect is short lived. A more effective treatment is Gaviscon (available in liquid or tablets) that in addition to antacids contains alginate. This works by coating the gullet which protects if from acid as well as helping to disperse acid pockets in the stomach.
If symptoms of acid reflux occur twice or more per week and/or very troublesome then proton pump inhibitors can be used. There are five main tablets in this class on the market though in recent years two have been made available in pharmacies without needing a prescription.
They are potent inhibitors of gastric acid secretion and should be taken about one hour before meals. In about 90% of cases, they will relieve symptoms of mild GORD though when taken over the counter, a typical course would be for about two weeks.
If symptoms persist, you should visit your GP who may prescribe them on ongoing basis and also decide on whether you may need other investigations.
Chronic GORD is associated with an increased risk of damage to the oesphagus. In particular, in up to 5-15% of cases, longterm acid reflux can result in changes to cells in the lining of gullet (Barretts oesophagus) that predisposes towards cancer.
When present, the risk of transformation to cancer is about 0.5% per year and though small, is usually monitored with endoscopy (camera tests of gullet). In fact, the rise in cancer of oesophagus in recent decades has been in large part attributed to this.
Apart from acid reflux, dyspepsia or indigestion is also common and in up to 10% of cases may be due to peptic ulcers.
These are invariably associated with the bacteria, Helicobacter pylori which increases gastric acid secretion. If you have non heartburn dyspepsia or reflux symptoms non responsive to therapy you can check for this ‘ulcer bug’ with a breath test. It can be easily eradicated with a course of treatment that includes antibiotics.
If you have ongoing symptoms, don’t suffer and make sure to go your GP and get checked out.
Dr Kevin McCarroll is a Consultant Physician in Geriatric Medicine, St James’s Hospital, Dublin.