I have tried to give a thorough explanation without boring anyone. This is
a question that comes up on Vocalist from time to time.
John
John J. Messmer, M.D.
Assistant Professor, Family & Community Medicine
Penn State College of Medicine
Reflux is common to most people over 35. The diaphragm serves to squeeze
the lower esophagus and prevent acid and stomach contents from moving up the
esophagus. This is less efficient after age 35. In addition, some people
have the stomach push up through the opening, or hiatus, in the diaphragm.
This is a hiatal hernia and it can allow even more avid reflux. It is
really only a problem when it is persistent, symptomatic or causes
associated problems.
The esophagus tends to contract (peristalsis) in a way that strips it of its
contents in a downward direction. Sometimes the peristalsis is upset or
disrupted and when acid starts to move up, the esophagus is not able to move
it down efficiently. This is also increased with age although it is usually
not a big problem until the 70's.
Some things increase the physical act of refluxing: being overweight
(presses the stomach to force it to empty upward), mint, nicotine,
carbonated beverages, large meals, high fat meals, alcohol, tight clothing
across the abdomen, being supine, bending over. Some things increase the
production of acid: fat, protein, and caffeine. Although they are often
blamed, citrus, tomato, and pepper do not increase acid or reflux. If one
gets reflux after these foods, the taste makes one believe it is
contributing. Chocolate increases reflux because of the fat and caffeine.
Milk does because of the fat and protein.
Reflux can cause heartburn, chest pain from the esophageal spasms,
hoarseness, sore throat, ear pain, poor vocal quality, and can increase the
risk of esophageal scarring (stricture) and esophageal cancer. Nicotine
increases the cancer risk.
There are several things to do if one has reflux. Fix or eliminate the risk
factors (see above), suppress the acid, or reduce the ability of reflux to
happen. Sometimes just 5-10 lb weight loss can benefit reflux. There are
three ways to reduce acid: antacids which neutralize it are effective for an
hour or two; histamine receptor type 2 blockers (cimetidine, famotidine,
ranitidine, nizatidine or Tagamet, Pepcid, Zantac and Axid respectively)
which work for 12 or more hours and reduce about 70 percent of the acid or
proton pump inhibitors (Prilosec [omeprazole] or Losec in some countries,
Prevacid [lansoprazole], Aciphex [rabeprazole], Protonix [pantoprazole])
which work for 24 or more hours and reduce the acid by about 95 percent.
There are several ways to reduce the actual refluxing: raise the bed at the
head end since most refluxing takes place when supine; use Gaviscon which
foams up in the stomach to provide a barrier; metaclopramide which increases
the pressure at the lower esophagus (cisapride may still be available
outside the US - this also does this); surgery to tighten the lower
esophagus. The surgery now is done by scope so in the hands of a skilled
surgeon is fairly effective and safe.
In some cases, more than one of the above are used.
The expensive medications are only needed if one fails the lower potency
drugs. In my experience, almost everyone will get better with weight loss
or caffeine reduction. The rare thin person with reflux may ultimately need
surgery.
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