Stomach acid is incredibly strong – about 100 times stronger than vinegar – so when it gets into the wrong place from the stomach up into the oesophagus, it’s extremely unpleasant. Symptoms will depend on how high it goes and in what quantities, but range from an uncomfortable warmth or a burning sensation to chest pain that feels like a heart attack. I regularly see people who have not been able to eat or sleep properly for years because of acid reflux. Every time they lie down, their stomach acid washes up into their throat.
According to the NHS, up to 20 per cent of UK adults live with recurring acid reflux – termed gastro-oesophageal reflux disease (Gord) – and around 10 million are prescribed proton-pump inhibitors (PPIs), which reduce stomach acid by about 80 per cent. Research we’ve carried out at the Functional Gut Clinic suggests that in most cases, it’s “prescription first, diagnosis never”. More than half the patients we have surveyed have been on PPIs for more than two years, and one in five for more than a decade. Very few had been through tests to find the cause or given a proper diagnosis.
Unfortunately, long-term PPI use carries its own risks. Evolution has told us that having stomach acid is important, so acid reflux itself is your body warning you there is a problem. It’s important to know what could be causing it, what measures can get it under control and when you should investigate further.
First, rule out cancer
Acid reflux can be a symptom of oesophageal cancer, but it can also be a cause if left untreated for long enough. Whenever you get damage in the body, whether it’s sunburn on the skin, smoke in your lungs or acid in your oesophagus causing ulceration, bleeding and inflammation, there’s a chance that when the cells repair themselves, something might go wrong. That’s when you get the changes that can lead to cancer.
Oesophageal cancer can be late to give symptoms, but if you’re experiencing acid reflux and heartburn, along with difficulty swallowing (you find food is slow or uncomfortable to go down) or weight loss – especially if you have a family history of oesophageal cancer too – it’s important to see your doctor for a proper diagnosis. This might require an endoscopy, when a long thin tube with a camera is used to examine the inside of the body. A less invasive test uses a little sponge inside a capsule on a fine string. You swallow it, and when it’s pulled out, it takes some of the cells from your throat so they can be sent to a laboratory. It’s rather like a smear test of your oesophagus.
Ditch the burgers
If cancer is ruled out, there’s a lot you can do before turning to medication. The stomach is a bit like a pump. To work normally, with everything going in the right direction, there are valves at the top and the bottom that must open and close at the right times.
A big roll of belly fat constantly weighing down your stomach like a dumbbell increases the pressure upwards on the valve. Large food portions also raise the pressure, as well as eating too many fatty foods, which really slows down digestion, as you need to mix the fat up with lots of different chemicals in the stomach for it to digest properly.
Quick-onset reflux, which occurs quite soon after you’ve eaten, is often caused by fatty meals such as takeaways, burgers, fry-ups or pastries. Late-onset reflux, which might come on four or five hours after eating, is more likely to come from food that is broken down in the lower gut, such as garlic and onion, which can be hard to digest.
Losing belly fat, reducing portion size and changing diet can all have a huge impact on acid reflux. A good “rescue diet” that will sail through the system is white basmati rice, white fish and lightly boiled veg.
Medicating – and the potential dangers of PPIs
Everything you eat and drink – and all the bugs, bacteria and pathogens that come with it – is dealt with by stomach acid. It’s a bit like the disinfectant in a swimming pool. If you reduce that acid by 80 per cent by taking PPIs for years, then all the pathogens can start to proliferate and colonise the bowel. I see patients who have started on PPIs because of heartburn, stayed on them and then gradually started to experience chronic symptoms such as bloating, diarrhoea or gastroenteritis. These are probably caused by lack of stomach acid.
We need stomach acid for a variety of important functions – for example, it helps us absorb vitamin B12. If there are 10 or 12 different side effects from not having stomach acid, over time they start to add up. There have been lots of reports linking long-term PPI use to kidney disease and Alzheimer’s disease.
If you’re making lifestyle changes to tackle acid reflux, but want to bring symptoms down in the meantime, start with over-the-counter medicines such as Gaviscon or Rennie, which neutralise stomach acid rather than reducing it. Taking them in a regimented manner after meals and before bed can give you that added protection.
If symptoms persist, and a GP prescribes PPIs, they should be taken for eight weeks maximum.
The tests that can provide answers
If lifestyle changes haven’t helped, and you’ve had an endoscopy for a visual inspection, physiology tests can show how everything is working. Oesophageal manometry and pH testing really give objective answers. These tests show how strong the valves are, how well your swallowing muscles work, and measure how much acid reflux you have over a day. An electrogastrogram is a bit like an electrocardiogram except on the stomach rather than the heart, measuring nerve and muscle function.
Are bacteria an issue?
It may also be worth testing for the presence of certain bacteria. About 60 per cent of the patients we see with acid reflux who are considering surgery test positive for small intestinal bacterial overgrowth. This is where bugs proliferate in the small intestine and start to break down food before you’ve had a chance to digest it, making you gassy and bloated. This can be diagnosed using a hydrogen and methane breath test and can often be dealt with using a short course of antibiotics.
Helicobacter pylori (H. pylori) is a bacterium that has found a way to live in the stomach and protect itself from stomach acid. It’s very common, increases with age, and many of us carry it without symptoms. However, if it does start causing symptoms such as reflux, it’s time to get rid of it with antibiotics as the inflammation and cell damage might lead to precancerous cell changes.
When surgery is the only cure
For around one in 1,000 cases of reflux (and one in 10 of those referred to our specialist clinics), surgery is the best option. When the hiatus – the opening in the diaphragm where the oesophagus goes – is bigger than it should be, everything is too loose and more liable to move up and down at the wrong time. It may be a weakness that you’re born with or that you’ve developed with age.
Keyhole surgery under a general anaesthetic is the most common surgical procedure. This involves making a new valve by wrapping the top part of the stomach around the lower oesophagus.
It’s worth noting that the vast majority of acid reflux can be solved through lifestyle changes. I’m not blaming Deliveroo, but I’m sure the number of drivers who rock up outside buildings to deliver a sneaky McDonald’s just before bedtime are contributing to the increasing prevalence of the condition.
My concerns were ignored – I had to do my own research to get a diagnosis
Lauren Jackson, 35, is a sexual health nurse from Preston
Earlier this year, I started to suffer from acid reflux and bloating. It was coming on every evening, and by bedtime, it was so uncomfortable I could hardly lie down as that made it even worse. There were huge amounts of belching.
I started buying Rennie and eliminating any foods that might be triggering. I’d known from past experience that spicy food and tomatoes could be difficult for me to digest. I went on a really careful elimination diet, but that didn’t help. By August, I was also experiencing sharp pains in my abdomen, so I saw my GP.
That appointment began a long process of what felt like not being listened to. When the initial stool tests found no blood or red flags for bowel cancer, there was no further examination or investigation at all. I was just diagnosed with IBS and acid reflux and asked to keep a food diary to understand my triggers. I’d already done all that and I wanted answers.
I began doing my own research and after four visits to four GPs, I asked for a test for H. pylori, a bacterial infection which can cause indigestion, an ache or burning pain in the upper abdomen, bloating and nausea. My GP seemed unconvinced but agreed to the test, which came back positive.
I was prescribed two-high strength antibiotics and they did the trick – my symptoms have cleared up now. If left untreated, the damage caused by H. pylori can lead to stomach cancer, so I’m glad I could advocate for myself.
As told to Anna Moore