If you are one of the more than 60 million people in the United States who suffer from acid reflux disease and heartburn at least once a month, then you are familiar with acid reflux symptoms like these, which can range from annoying to very painful. But the effects of acid reflux disease – caused by recurrent backflow of acid and other stomach contents into the esophagus - are more than just physical.

A new survey conducted recently shows that acid reflux disease, also known as gastro esophageal reflux disease (GERD), can have a profound impact on emotional well-being as well as on activities of daily life.

For instance, 28 percent of sufferers say onsets of acid reflux adversely affect their sex lives, 51 percent report that symptoms keep them awake at night, arid 76 percent say the disease has affected them emotionally.

The surveyors conducted telephone interviews with 1017 acid reflux sufferers who may or may not have had erosive GERD. A more severe form of the disorder, GERD is known as “erosive” when the esophagus lining is damaged from long term acid exposure.

The survey also revealed that almost half (48 percent) of all respondents with acid reflux disease waited four months or more before going to a physician, and 25 percent waited more than a year.

Fortunately, acid reflux treatment is available for the discomfort associated with the disease. If you think you may be experiencing symptoms of this condition, talk to your doctor.

While over-the-counter remedies may be appropriate for relief of occasional heartburn, prescription acid suppressants called proton pump inhibitors (PPls) have been shown to be the most effective agents in eliminating acid reflux symptoms and also are very effective in managing and preventing complication associated with the condition.

Aciphex (rabeprazole sodium), the first PPI to be approved in the United States in more than four years for the treatment of erosive GERD and certain other related conditions, is now available in pharmacies. Aciphex has been shown in clinical trials to offer acid suppression with once-daily dosing and consistent symptom control with significantly effective healing rates in erosive GERD.

In clinical trials, Aciphex demonstrated a favorable side-effect profile. Headache was the most common side effect assessed as possibly related to  Aciphex (2.4 percent vs. 1.6 percent for placebo). Aciphex is contraindicated in patients with known sensitivity to rabeprazole, substitute benzimidazoles or any component of the formulation. As is the case for other acid reflux treatments like proton pump inhibitors, symptomatic response to therapy with Aciphex does not preclude the presence of gastric malignancy. Proton pump inhibitors, however, constitute an established class of drugs that has been shown to be safe and well-tolerated.

NICE recommends either a ’step up’ or a ’step down’ approach, depending on the severity of your acid reflux disease. There are 5 five levels, starting with the mildest treatment (antacids/alginates) through H2 antagonists, to rising doses of PPIs. For example, if endoscopy has shown that you have ulcers in your esophagus or Barren’s esophagus, you will start on the highest ‘healing’ dose of a PPI - level 5. The dose can eventually be cut down once the symptoms have improved, to a level that continues to keep you symptom-free.

On the other hand, if you have mild symptoms and no need for endoscopy, you may be started on level 1, with an antacid-alginate combination and advised on lifestyle. If this does not work, your doctor may add an H2 antagonist - level 2.

Depending on your progress after that, you will pass up or down the scale. All patients should have their own ‘treatment plan’ that guides them on how to manage their own symptoms, and this can often be stopped when their esophagus eventually heals and the symptoms disappear.

However, the fact that you are able to stop the treatment doesn’t mean that you can now stop going to your doctor.

Most people with gastro-esophageal reflux disease (GERD) require long term management. The guiding principle for long term management is to step down to the treatment that is least costly but still effective in controlling your GERD and acid reflux symptoms.

Finding the right level of management may take time in some patients. Patients returning with a relapse after a trial without treatment should be restarted on the initially successful therapy and then have treatment stepped down as appropriate. For patients who require only intermittent short courses of antisecretory (acid-lowering) therapy, it may be more effective to give a proton pump inhibitor at full dose than to titrate treatment up from either half dose of PPI or a standard dose of H2 receptor antagonist.

By optimizing the treatment in these ’steps’, endoscopy is kept to a minimum. If a particular acid reflux treatment successfully controls a patient’s symptoms, the doctor can be assured that the esophagitis has healed, and there is no need for further endoscopies.

Even when the patient needs to continue on long-term PPIs because of severe esophagitis (Los Angeles stages (C) and (D)), repeat endoscopy is not always needed, as it is safe to assume that if the GERD symptoms are absent, the esophagitis has healed. On the other hand, patients in these categories must have repeat endoscopies if they still have symptoms despite standard daily doses of PPIs.

The groups of patients who must be kept on continuous treatment include:

Patients with ulcers in the esophagus that have been induced by an NSAID and who have no choice but to continue with it because they have chronic pain (such as from arthritis). They should remain on maintenance doses of PPIs (level 4).

Patients with severe GERD, such as Barren’s esophagus or an endoscopy-proven ulcer, should also remain on maintenance doses of a PPI (level 4).

Patients whose very severe acid reflux disease has been complicated in the past by stricture, ulcers and hemorrhage should be left on full doses of PPIs (level 5).

‘Prokinetic’ drugs, designed to speed up the passage of food from stomach to duodenum, such as metoclopramide (Maxolon, Gastro-bid) can be added, if needed, to help prevent bloating.

Cimetidine (Tagamet) was the first of this group of acid reflux remedies. It revolutionized the treatment of gastric and duodenal ulcers, but it was marginally less successful when tried against reflux esophagitis. Patients taking it in the early trials found that their symptoms were much less, but endoscopy appearances showed that they still had a moderate degree of inflammation in the esophagus.

The early doses were possibly too low, and many people with acid reflux disease have to take double the original dose of 400 mg to keep their symptoms at bay.

Ranitidine (Zantac) is another H2 receptor antagonist. It is similar in effect to cimetidine, and the usual dose is 300 mg each evening. The dose can be raised up to as much as 1500 mg daily for added benefit, although most doctors would prefer not to go so high, and use another acid reflux treatment, probably a proton pump inhibitor, instead.

Newer H2 antagonists include famotidine (Pepcid) and nizatidine (Axid). They are similar in action to cimetidine and ranitidine, with little to choose between them.

All drugs, including these GERD and acid reflux remedies, may produce side-effects, and acid-suppressant drugs are no exception. H2 receptor antagonists should be used with caution in people with liver or kidney problems or who are pregnant or breast feeding. They may ‘mask’ the symptoms of stomach cancer, so if you have one or more of the ‘alarm’ symptoms your specialist will rule out stomach cancer before prescribing one.

Side-effects of this group of drugs are relatively rare, but they include diarrhea, headache, dizziness, rash and tiredness. Much rarer are effects on the heart rhythm, on the bone marrow and occasional reports of enlarged breasts in men (gynaecomastia) and impotence.

Cimetidine has a disadvantage compared with other drugs in this group, in that it interacts with drugs that use the same type of mechanism in the liver for their breakdown. So it cannot be taken alongside warfarin (an anti-clotting drug), phenytoin (for epilepsy) or theophylline (for asthma).

The other drugs in this group may be taken instead.

Proton pump inhibitors

Proton pump inhibitors (PPIs) act on the acid-producing mechanism at an earlier stage in the process than H2 antagonists, so that they completely eradicate acid, rather than reduce it, from the stomach contents.

The first PPI was omeprazole (Losec). It has since been joined by esomeprazole (Nexium), lansoprazole (Zoton), pantoprazole (Protium) and rabeprazole (Panel).

As with the H2 antagonists, PPIs are so efficient in removing symptoms in reflux disease, even when it is severe, that they can ‘mask’ a stomach cancer. When a person shows ‘alarm features’ the specialist team must rule out a stomach or esophageal cancer before prescribing them.

Side-effects of PPIs are similar to those of the H2 antagonists. The patient leaflet for PPIs list alt the side-effects that have been reported: they look horrendous, but it must be remembered that they are all very rare. Most people find these acid reflux remedies easy to tolerate and that they have no side-effects. However, it is important to read the leaflet, so that if a problem does arise, you can tell what it is, and deal with it accordingly.

GERD and acid reflux treatments:

1. Antacids and alginates.
2. H2 receptor antagonists (such as ranitidine and cimetidine).
3. ‘As needed’ doses of proton pump inhibitors (such as omeprazole and lansoprazole),
4. Maintenance low-dose proton pump inhibitors.
5. Healing high-dose proton pump inhibitors.

Remedies For Acid Reflux - Antacids and Alginates

Antacids describe themselves. They are alkaline based remedies for acid reflux, designed to neutralize the acid produced by the stomach. Alginates are derived from seaweed (agar) and are designed to release a gel into the lower esophagus that will protect the surface from acid attack, or act as a ‘raft’ that floats on the top of the stomach contents and prevent the upward flow into the esophagus. Both types of treatment, especially
if given together, are effective for mild to moderate GERD and acid reflux disease.

Antacids are usually aluminum or magnesium compounds. They range in convenience and cost - the cheaper preparations tending to be less palatable than, but just as effective as the dearer ones. They can all be bought from pharmacies to save you having to wait for a prescription.

The basic antacid style of remedies for acid reflux are aluminum hydroxide and magnesium carbonate or trisilicate. Pharmacies have dozens of formulations of them to suit your taste and preference. Co-magaldrox is a mixture of aluminum and magnesium hydroxides, marketed as Maalox or Mucogel.

Remedies for acid reflux which contain  aluminum and magnesium compounds are poorly soluble in water, and act for a long time if they remain in the stomach. The main difference between them is that aluminum-containing antacids tend to constipate and magnesium compounds tend to loosen the motions, so combining them, in theory, minimizes these effects on the bowel.

If you need a longer action, you can choose a combination of an antacid with an alginate. The sticky alkaline barrier that they form on the top of the stomach contents combines neutralization of the acid with the raft principle mentioned above. Among alginate-containing products are Algicon, Gastrocote, Gaviscon, Peptac, Rennie Duo and Topal. There are many more.

An alternative acid reflux treatment to alginate is a silicone, such as simeticone, (dimeticone). This is a ‘de-foaming’ agent that is thought to make it easier to belch, reduce bloating, and allow faster passage of food and digestive juices through the stomach, reducing reflux as it does so. It is particularly useful in easing hiccups. Antacid-simeticone preparations include Altacite Plus, Asilone and Maalox Plus. Again, there are many others.

All antacid-alginate or antacid-simeticone combinations of acid reflux treatments are popular over-the-counter drugs, so they must work for many people. If you find one that suits you, you may as well stick to it. However, if you have to take one every day, you need to step up your treatment into the acid-suppressant drugs, the H2 receptor antagonists or the proton pump inhibitors.

Smoking is a suicidal habit for anyone, no matter how healthy they seem. It is even worse, if that is possible, for people with acid reflux and GERD, because it irritates the already inflamed esophagus and prevents it healing.

It narrows the already compromised circulation to the affected area of esophagus, something you absolutely can’t afford to happen, as it increases the risk of a hemorrhage or a perforation from it. Worst of all, smoking increases the acid production in the stomach and damages the mucosal protective barrier of mucus.

In every way, even smoking one or two cigarettes a day will reduce your chances of dealing successfully with GERD. So if you are a smoker, you must become a non-smoker before you can cure acid reflux.

How, exactly, does being a smoker harm you?

Tobacco smoke contains carbon monoxide and nicotine. The first poisons the red blood cells, so that they cannot pick up and distribute much-needed oxygen to the organs and tissues, including the heart muscle. Carbon monoxide-affected red cells (in the 20-a-day smoker, nearly 20 per cent of red cells are carrying carbon monoxide instead of oxygen) are also stiffer than normal, so that they can’t bend and flex through the smallest blood vessels. The gas also directly poisons the heart muscle, so that it cannot contract properly and efficiently, thereby delivering a ‘double whammy’ of damage to it.

Nicotine causes small arteries to narrow, so that the blood flow through them slows. It raises blood cholesterol levels, thickening the blood and promoting degeneration in artery walls. Both nicotine and carbon monoxide encourage the blood to clot, multiplying the risks of coronary thrombosis and stroke.

Add to all this the tars that smoke leaves in the lungs, which further reduce the ability of red cells to pick up oxygen, and the scars and damage to the lungs that always in the end produce chronic bronchitis and sometimes induces cancer, and you have a formula for disaster.

Losing weight

If you can exercise easily without bringing on a cough or wheezing, do so. The best way is to find an exercise that you enjoy (cycling, swimming, brisk walking, ballroom dancing - it doesn’t matter as long as you are likely to stick to it), and do it for at least half an hour, preferably an hour, on three or four days a week.

It should be brisk enough to make you breathless, without causing you distress. If you can manage this regimen, you will find that you can lose a pound or two each week - and that amounts to 50 pounds a year! If this is combined with eating smaller amounts, it will ease your discomfort from an over-full stomach and decrease the pressure inside the abdomen that tends to push your stomach contents upwards, causing the acid reflux and heartburn symptoms.

The secret of losing weight by eating less is to eat slowly. Most fat people tend to wolf down their food, taking 15 minutes or less to polish off a large meal at home. If they could spread the time to more than half an hour, they would eat a lot less. Try it – you could be pleasantly surprised.

The reason for this is that once we feel hungry, it takes about half an hour for the feeling to die down, no matter how much we eat (within reason). If we eat our main meals round a table, having conversation with friends and family, eating slowly and waiting between courses, the feeling of satiety (fullness) starts in around half an hour, regardless of how much we have eaten (provided, of course, we have eaten something!). So if we eat slowly enough, we feel full before we have eaten a large amount, and we lose weight.

A lot of families seem to have abandoned this habit of eating around the family table, and we face a huge problem of obesity. The French eat as they have always done, taking their time and savoring every bite. Go to Paris and try to spot an obese adult - he or she is much more likely to be a tourist than a local. The French are far less affected by the obesity plague than we are.

Which foods?

The second point is that it doesn’t really matter, within reason, what food you eat. People with digestive problems often ask which foods cause their symptoms and which are unlikely to do so. They are surprised to find that there are very few types of food that cause GERD or acid reflux symptoms. A minority of sufferers find that fried foods upset them: others find that tea or coffee or similar hot drinks do so.

Many more rue the glass of spirits that well-meaning friends have offered them. The rule about food is that if you find one that brings on heartburn or discomfort, then avoid it. Everyone is different. It is more important to eat a variety of foods that don’t obviously induce the symptoms rather than to go on a restrictive diet. You will almost certainly find, as you change from big meals to small portions eaten slowly, that you return to eating foods that in the past you thought made you feel ill. This is why I’m not devoting a big section in this blog dedicated to diets. They don’t work in GERD, except in so far as you will find by trial and experience which foods suit you and which ones don’t.

Sleeping position

The third point is about raising the head of the bed. Of course, it is meant to keep the upper body semi-upright, to avoid reflux passing horizontally from stomach to esophagus. I’ve found in practice that all it does is to make people slide down the bed while they sleep so that they end up curled up, flat on the mattress.

That is no advantage to them, and can result in a disturbed night. So I would add that if you are going to raise the bed head, do it by only 2 or 3 inches, and put a foot-plate at the bottom of the bed, so you can’t slip downwards.

To be frank, raising the bed doesn’t often help: if you really have to keep upright overnight, you may well find that sleeping in an easy chair with a back and side arms is more effective.

Once your lifestyle changes have started to improve your heartburn symptoms, you can then return to bed, using two or three pillows to keep your body at a reasonable angle from the horizontal.

Smoking

This point is a very serious one. Smoking has such a bad effect on GERD that I felt that it deserved a separate article to itself - acid reflux causes - smoking. If you smoke, then you need to read the smoking related articles on this site. Stopping smoking is the best thing you can do for your health and probably the best natural treatments for acid reflux disease there is (if you’re a smoker).

If you don’t smoke, at least let relatives or friends who smoke read it, because the message to stop is just as much a general one as it is specifically aimed at GERD.

Once treatment starts, you should also be reassured that you don’t have an illness that is life-threatening. Many people with GERD and acid reflux disease are frightened that they may have cancer or heart disease: once your diagnosis has been made clear you can cast these worries aside and get on with your life, content in the knowledge that GERD can be cured.

Once you understand that, you are already treating yourself and the cure has started before you have swallowed your first dose of whatever acid reflux medication you are taking.

The wrong lifestyle has played its part in most people with GERD, and changing to a healthier lifestyle is the first step towards finding your cure for acid reflux. The guidelines on lifestyle for GERD include:

• Lose excess weight.
• Stop smoking.
• Reduce alcohol intake if it is above two standard drinks (of wine) a day.
• Raise the head of the bed at night and use plenty of pillows (to try to stay reasonably upright when asleep).
• Eat small meals often, rather than one large meal at any time.
• Avoid hot drinks.
• Avoid alcohol and food less than three hours before going to bed at night (to avoid a full stomach when lying horizontal).
• Avoid drugs that may affect the normal peristalsis of the esophagus or the sphincter (nitrates, anticholinergics, tricyclic antidepressants).
• Avoid drugs that may damage the esophageal mucosa (NSAIDs, potassium salts, bisphosphonates).

So by making some simple lifestyle changes and working with your doctor, you should be able to find some natural acid reflux treatments that will cure acid reflux disease for good.

Alcohol

I’m sorry to sound a killjoy, but if you have acid reflux disease or GERD, you must be very careful about your alcohol consumption. The neater the alcohol you drink, the more likely you are to provoke an attack of acute GERD. So, although as a lover of Malt Whiskey, it pains me to write this, ease off on the spirits. Confine yourself to the odd glass of wine, preferably with meals. That’s how the French approach alcohol, and it’s very civilized. They have less GERD than we do.

Clothing

Not all acid reflux and GERD sufferers are the same. Some can tolerate coffee or fatty foods, others can’t. Being overweight and eating large meals are certainly one of the main causes of acid reflux and GERD, and so is pregnancy (but at least that’s only a short term state).

Tight clothes can put pressure on the abdomen, so that if I were writing this book a generation ago, I would have mentioned corsets. However, I’m reliably informed (by my slim wife) that women no longer squeeze into restrictive clothing – they just ‘let it all hang out’. Any tight band across the middle, such as a belt, may induce acid reflux symptoms. I leave it to the individual woman (or man) to judge whether or not that is a factor in their GERD.

Medication

Some prescription drugs can contribute to GERD by causing the sphincter at the cardia to relax. They include the ‘tricyclics’ used to treat depression. They are usually easily spotted, because their generic name (seen in small print under the trade name) often ends in  -amine  or  -ine.  Among them are amitriptyline, amoxapine, clomipramine, imipramine, lofepramine, nortriptyline and trimipramine.

‘Anticholinergic’ or ‘atropine-like’ drugs prescribed to treat bowel spasms or irritable bowel syndrome can do their job only too well and relax the gastro esophageal sphincter, too. They include dicyclomine (also called dicycloverine), hyoscine and propantheline bromide.

Atropine sulphate tablets are given on prescription but are also available over-the-counter, mainly as Actonorm powder, which is a mixture of atropine, aluminum, calcium carbonate, magnesium, sodium bicarbonate and peppermint oil. This, too, can relax the gastro esophageal sphincter and provoke attacks of GERD symptoms.

Another group of drugs that may be one of the causes of GERD is the ‘nitrates’ prescribed to open the coronary arteries for people suffering from angina. Among them are glyceryl trinitrate and isosorbide trinitrate and mononitrate. If your chest pain becomes worse when taking these drugs, you either are having more serious heart pain than you thought, and should urgently see your doctor, or the pain is caused by GERD. Either way, you need help.

Some drugs directly irritate the esophageal mucosa. They include the aspirin-like non-steroidal anti-inflammatory drugs used to treat chronic pain; potassium salts that are sometimes used in people taking drugs to lower blood pressure; and the bisphosphonates given for osteoporosis. If you are on treatment for any of these conditions, and think you may be taking one of these types of drug, you should discuss it with your doctor.

So if you have GERD and are taking drugs for other conditions, check with your doctor that your treatment is not actually one of the acid reflux causes and thereby worsening your GERD symptoms. There are always alternative acid reflux natural treatments to be found if they are.

People with digestive problems often ask which acid reflux foods cause their symptoms and which are unlikely to do so. They are surprised to find that there are very few types of food that cause GERD and acid reflux symptoms. A minority of sufferers find that fried foods upset them: others find that tea or coffee or similar hot drinks do so.

Many more rue the glass of spirits that well-meaning friends have offered them. The rule about food is that if you find one that brings on heartburn symptoms or discomfort, then avoid it. Everyone is different. It is more important to eat a variety of foods that don’t obviously induce the symptoms rather than to go on a restrictive diet.

The main consideration you should be focusing on, with any kind of acid reflux diet, is to stop eating big meals. You will almost certainly find, as you change from big meals to small portions eaten slowly, that you return to eating foods that in the past you thought made you feel ill. This is why I’m not dedicating a lot of space to so called acid reflux diets. They don’t work in GERD or acid reflux disease, except in so far as you will find by trial and error and experience which foods suit you and which ones don’t.

Smoking not only increases the acid production by your stomach, it will also help to relax that vital gastro-esophageal sphincter. Worse, if you continue to smoke, you will steeply increase your chances of converting the chronic inflammation in your lower esophagus into cancer. The sooner you give up cigarettes and tobacco, the better your chances of your symptoms disappearing and your survival into a happy and healthy old age.

At the cardia, just where the esophagus becomes the stomach, there is a ring of muscle around it, within its wall. Imagine a bicycle inner tube that is semi-inflated with an elastic band around it, gripping it a little and narrowing it. Then transfer that image to the esophagus as the inner tube, and the sphincter muscles as the elastic band.

Sphincters exist at crucial areas of the gut where it is important for there to be no back-flow. The first sphincter in the line between mouth and anus is the one between the esophagus and the stomach, at the cardia. The next is at the pylorus, where the food passes from the stomach into the duodenum. The third is where the contents of the small bowel (the ileum) enter the large bowel (the caecum), so it is called, fairly obviously, the ileo-caecal sphincter. The last is between the rectum and anus, the anal sphincter. That’s the one that helps to make us sociable human beings: it allows us to refuse the natural call to pass a motion.

To return to the gastro-esophageal sphincter. The angle at which the esophagus meets the stomach, as mentioned above, is important in preventing reflux. However, so is the efficiency of the sphincter at the same site. It opens (in other words, the muscle of the sphincter relaxes) to let food and drink pass from esophagus to stomach, and it closes  to prevent the food flowing back from  stomach to esophagus. It is a one-way valve that normally works perfectly.

As well as the sphincter muscles themselves, there is another group of muscles that keeps this valve structure intact. These are the obliquely positioned muscles that keep the esophagus and stomach at the appropriate angle to each other, much like a sling or hammock. Without these muscles, the angle between esophagus and stomach would flatten out and the bottom end of the esophagus would open in a straight line full on to the stomach. That would make back-flow very much easier.

Such back-flow pressures mount up when the stomach, full of food, starts its job of digestion. Like the esophagus, the stomach wall has peristaltic waves flowing through it, which propel the food from above downwards, towards the outlet at the pyloric sphincter into the duodenum. However, it is also subject to chaotic churning waves of muscle activity that are helpful in mixing the stomach contents thoroughly with the digestive juices. If the gastro-esophageal sphincter and the oblique muscle fibers are not working properly and together, this may allow the chaotic waves to push the stomach contents backwards, up into the lower esophagus – and this is acid reflux, and the start of GERD.

The last 5 centimeters or so of the esophagus lie under the diaphragm in the abdomen. The esophagus meets the stomach at its upper right-hand surface, not quite at the top. If the stomach was a clock face, and you were looking at it from the front, the meeting of the esophagus and the stomach (the esophageal-stomach junction) would be at 11 o’clock.

This junction is the ‘cardia’. It meets the stomach at an angle, so that food slides easily downwards from the esophagus into the bottom 90 per cent of the stomach. It is not unlike tipping a glass to one side when you pour a fizzy drink into it, to avoid turbulence and froth. The angle should also ensure that, if there is any reverse movement of food upwards in the stomach, it passes by the entry into the esophagus (the cardia) and ends up in the top 10 per cent of the stomach. Continuing the analogy with the clock face, that’s the 12 o’clock area, or the ‘fundus’.

The fundus, being the uppermost part of the stomach, is virtually an unexpanded balloon. It is a safety valve that gathers any gas that has been swallowed with food (that’s why we ‘burp’ babies after their feeds) or produced during digestion. It normally sits neatly under the diaphragm.

The esophagus is a very muscular tube. The action of the autonomic nerves causes it to contract and relax in a very controlled to anus, and are the means by which food, and then faeces, are passed onwards. If peristalsis fails, the food simply sticks where it is lying. Liquid may trickle downwards, but solids will stay in a lump, stretching the tube walls and causing serious discomfort.

Three types of muscle contractions make up the peristaltic process:

1. Once we start to swallow, primary peristaltic waves ripple down the esophagus, pushing food in front of them at a rate of 5 centimeters a second.
2. If the primary peristaltic waves don’t manage to empty the contents of the esophagus into the stomach, a secondary wave starts, about halfway down the esophagus. This reinforces the primary wave, and sometimes it can be felt as an uncomfortable, almost indescribable, feeling, deep in the chest. It is a main symptom in many acid reflux cases, and readers with GERD will almost certainly recognize it.
3. Radiologists categorize a third form of muscle contraction in the esophagus, which they describe as ‘tertiary’ when they are watching the progress of barium swallow studies. They occur in one segment of esophagus at a time. They don’t appear to be involved in swallowing, and don’t propel food forwards. We don’t know why they appear. One suggestion is that they are a way of keeping the esophageal muscles in tone between meals, while waiting for the next lump of food to come down.

Peristalsis is vital for transferring solid and semi-solid food from the back of the throat into the stomach. If we are upright, liquids can trickle down the esophagus by themselves. Once we swallow a liquid, as long as there is no obstruction to its flow, it enters the stomach by gravity alone. However, peristalsis is needed to ensure that fluids won’t return up from the stomach into the throat. Without it, if you swallowed a drink when lying flat, or even upside down, the drink or food would flow back into the mouth.

My colleagues and I in my year at medical school have graphic memories of being taught about swallowing. One of our physiology lecturers (a particularly excellent doctor), brought into the lecture hall a pint of beer, climbed on to the demonstration table, stood on his head facing us, then drank the beer in one go. He didn’t find it difficult and didn’t spill a drop. Unfortunately he declined to perform an encore!

So the rippling muscles of the esophagus ensure that the passage of food and drink through it is one-way only. This is very important. If food travels in the other direction you are sick - vomiting - and you feel awful with it.

At its lower end the esophagus passes through a hole - in Latin, this is the hiatus - in the diaphragm, a sheet of muscle that separates the contents of the chest from the organs in the abdomen. Below the diaphragmatic hiatus, the esophagus becomes the upper part of the stomach. How it does so, and how the stomach and esophagus relate to the diaphragm, are crucial to understanding GERD.

It is vital that the one-way flow of food through the esophagus is continued when it reaches the stomach. Once in the stomach, it has to stay there for a while to allow mixture of the food with the stomach’s digestive juices, and then pass forward into the duodenum, the first part of the small bowel. The stomach’s digestive juices are very acid so that they can break down proteins (mainly meats and fish) into their constituent parts, before being taken up through the small bowel wall into the body. The stomach wall is largely protein, so it would digest itself if it weren’t protected against its own juices.

That protection takes two forms. There are four main types of ’secreting’ cells in the stomach lining. One provides the acid (hydrochloride acid) that initiates protein breakdown. Another provides the pepsin that digests the proteins even further. A third provides a thick mucus that spreads over the whole of the stomach lining to protect it from acid attack. The fourth secretes bicarbonate that neutralizes excess acid, adding more protection against self-digestion.

At the lower end of the stomach the bicarbonate secretion begins to predominate, so that the duodenum receives a mixture of semi digested food at a much less acid level - almost neutral - than the material in the main body of the stomach. When the protective mechanisms of mucus and bicarbonate break down or are diminished, the stomach does start to self-digest, leading to ulcers - exposed areas of stomach lining that are inflamed and eroded.

Stomach ulcers are usually due to a failure of the balance between the stomach’s digestive secretions and its self protection mechanisms. They are often called ‘peptic’ ulcers because the combination of pepsin and acid is a powerful cause of erosion of the underlying stomach wall.

Understanding this balance between digestive secretions and self protection is vital if you need to understand what is going on in GERD. If the acid and pepsin of the stomach somehow finds its way upwards into the lower esophagus, the balance between digestion and protection has gone. The cells that line the esophagus do not secrete a mucus protection or bicarbonate: they offer no protection at all against the acid and pepsin.

So if acid and pepsin enter the esophagus there is an immediate reaction. The cells respond with irritation and inflammation, and the brain interprets this as heartburn and pain. If the process continues for more than a few hours, ulcers form in the lower end of the esophagus; and when they eventually heal, they may do so with scarring that can narrow it. Long exposure of the esophagus to the stomach’s secretion can eventually lead to multiple scarring, bleeding and even perforation of the esophagus, complications that are obviously dangerous and life-threatening.

It’s crucial for normal health, therefore, that we keep the stomach contents out of the esophagus. The body tries its best to do so, using several mechanisms working together in mutual co-operation. They are the cardia, the sphincter and the diaphragm. Knowing how each of them contributes to keeping stomach juices out of the esophagus is essential to understanding what may produce acid reflux or GERD.

The esophagus is a muscular tube, and the muscles around it, along its length, coordinate their movements so that its contents are squeezed downwards, like emptying an inverted toothpaste tube from the base downwards to the nozzle.

Swallowing is not just the result of gravity. We transfer food towards the back of our throat using our tongue. Swallowing then becomes automatic, in that although we can feel the food slipping down towards the esophagus we cannot stop it from doing so. It is now under the control of the ‘autonomic nervous system’, a network of nerves that combine to control the movements of food through the rest of the gut, without our being aware of it.

When food hits the back of the throat (the pharynx) it stimulates two muscle reflexes: one shuts off the passages back into the mouth, the back of the nose and the lungs. The other squeezes the food down into the upper part of the esophagus. By doing this we can’t inhale and swallow at the same time. Food in the lungs is a disaster that can quickly lead to death.

The esophagus becomes irritated and inflamed, and sometimes even ulcerated and digested by them. So the symptoms range from the relatively minor, to the major ones of eventual bleeding, perforation and even cancerous changes.

GERD is very common and getting more common. Indeed, a generation ago, there would not have been the interest in acid reflux disease that there is now. This new awareness is largely because of two developments in our society - our much-publicized obesity epidemic and our frenetic lifestyles.

Being overweight - specifically being apple-shaped - means that there are large amounts of fat within the abdomen. This results in there being less room for the organs inside the abdomen, and therefore more pressure upon them. There is only one way for the pressure on the stomach to be relieved - upwards through the diaphragm. Hence the squirting of stomach contents up into the esophagus (especially when bending down or lying flat), and even the formation of hernias, in which parts of the stomach are pushed into the chest. (That’s why losing weight is one of the single most effective measures you can take against GERD / GORD.)

A frenetic lifestyle - snatching meals on the hoof - means that there are plenty of hours in the day in which the stomach secretes acid and pepsin (a protein-digesting enzyme) into its cavity, but has no food to digest. This can erode both the stomach wall and the esophagus above it. So modern man and woman have a two-pronged attack upon them.

There are many millions of people who suffer with the condition and visit their doctor for help. But they are only the tip of the iceberg - most people with heartburn treat themselves, and never bother to see their doctor.

This site is about GERD and acid reflux: how it arises, how it affects you, how it is investigated, and how it can be treated or even cured. It is for everyone with GERD who has to cope with heartburn and its related symptoms, and its consequences and complications.

Thankfully, we can be optimistic, because heartburn, of all ‘digestive’ problems, is the most easily treated. Provided you obey the rules and follow the appropriate advice on lifestyle and treatments, you can abolish it from your life.

Heartburn is not the whole story of GERD, though. If you have GERD you probably experience other symptoms that are just as annoying as heartburn. You may get fluid rising from your stomach into your mouth. That may be either ‘acid brash’, in which the fluid contains acid and bile, and tastes sour or bitter. Or it may be ‘waterbrash’, in which the mouth fills up with excess saliva.

You may find it difficult and painful to swallow solid foods, no matter how well you have chewed them. You may have constant or repeated pains in the centre of the chest or upper abdomen - ‘indigestion’ or ‘dyspepsia’ - that can accompany or alternate with the heartburn.

Lying flat or bending over may bring on the pain or make it worse. You may learn to avoid specific foods that seem to initiate pain. Eating too much at a time can also do it: you may already have started to eat smaller meals more often than before, in an attempt to prevent the symptoms.

Almost certainly you are used to taking anti-indigestion remedies, such as antacids or acid-suppressants. There are hundreds of proprietary medicines for GERD, and your pharmacist will probably have advised you on them and what they do. Yet still you are battling on, wondering if there is anything more you can do to help yourself.

My site is for people like you. It explains what GERD is, why it produces such pain and discomfort, and what you can do - in lifestyle changes, in eating healthily, and in medicines you can take - to become free of it and its complications. It also guides you on when you have to take things further, and how the doctors will investigate GERD to eliminate more serious illnesses or to find out whether or not you have a hiatus hernia that may need surgery to correct it. It explains what hiatus hernia is, and how it is operated on today.

Once you know the underlying cause of your symptoms, you will find it easier to cope with them and to comply with your doctor’s advice. The fundamental problem in GERD and acid reflux is that your stomach is ’squirting’ acid up into the esophagus.  Your stomach wall is resistant to acid attack, but your esophagus is not - and that’s what causes the pain.