Acid Reflux: Symptoms, Causes & Treatment Guide

What Is Acid Reflux and GERD?

Acid reflux occurs when stomach acid flows backward into the esophagus, causing heartburn and other symptoms. When this happens frequently (more than twice weekly) and causes symptoms or complications, it is called gastroesophageal reflux disease (GERD). Approximately 20% of adults in Western countries experience weekly symptoms.

The esophagus is the muscular tube that connects your mouth to your stomach. At the junction between the esophagus and stomach is a ring of muscle called the lower esophageal sphincter (LES). This sphincter normally acts as a one-way valve, allowing food to pass into the stomach while preventing stomach contents from flowing back up. When this sphincter relaxes inappropriately or becomes weakened, stomach acid can flow backward into the esophagus, causing the characteristic burning sensation known as heartburn.

It is important to understand that occasional acid reflux is completely normal and happens to almost everyone at some point. The stomach produces hydrochloric acid to aid digestion, and small amounts can occasionally escape into the esophagus without causing harm. However, when reflux occurs frequently, the repeated exposure to stomach acid can irritate and damage the esophageal lining, leading to symptoms and potential complications.

The condition affects people of all ages, though prevalence increases with age. Certain factors significantly increase the risk of developing GERD, including obesity, pregnancy, smoking, and certain medications. The economic burden of GERD is substantial, with billions spent annually on medications and healthcare costs worldwide.

How Common Is Acid Reflux?

Acid reflux is one of the most prevalent gastrointestinal conditions worldwide. Studies estimate that approximately 20% of adults in Western countries experience symptoms at least once per week, while up to 40% may experience occasional symptoms. The condition affects both men and women equally, though certain complications like Barrett's esophagus are more common in men.

The prevalence of GERD has been increasing over the past several decades, likely due to rising obesity rates and changes in dietary habits. In Asian countries, rates have traditionally been lower but are increasing as Western dietary patterns become more common. This epidemiological trend underscores the important role of lifestyle factors in the development of acid reflux.

What Are the Symptoms of Acid Reflux?

The most common symptoms of acid reflux are heartburn (a burning sensation behind the breastbone) and acid regurgitation (sour taste in the mouth). Other symptoms include difficulty swallowing, chronic cough, hoarseness, chest pain, and a sensation of a lump in the throat. Symptoms typically worsen after eating, lying down, or bending over.

Acid reflux symptoms vary significantly from person to person, and understanding the full range of possible symptoms helps in recognizing the condition. While heartburn is the hallmark symptom, many people experience "atypical" or "extra-esophageal" symptoms that may initially seem unrelated to digestion. These symptoms occur because stomach acid can affect not only the esophagus but also the throat, airways, and even the mouth.

The timing and triggers of symptoms provide important diagnostic clues. Most people notice that symptoms worsen after eating large meals, consuming certain foods, lying down shortly after eating, or bending over. Nighttime symptoms are particularly common because the horizontal position makes it easier for acid to flow back into the esophagus. Understanding your personal triggers is essential for effective management.

Typical Symptoms of Acid Reflux

The classic symptoms of acid reflux directly result from stomach acid contacting the esophageal lining. These symptoms are typically the first to appear and are most clearly linked to the underlying condition:

• Heartburn: A burning sensation behind the breastbone (sternum) that may radiate up toward the throat or back. Despite its name, heartburn has nothing to do with the heart - the sensation is caused by acid irritating the esophageal lining
• Acid regurgitation: The sensation of sour or bitter stomach contents rising into the throat or mouth, often accompanied by a bad taste
• Dysphagia: Difficulty swallowing or the feeling that food is stuck in the chest, which may indicate esophageal narrowing or inflammation
• Chest pain: Discomfort or pain in the chest that can sometimes be confused with cardiac chest pain
• Pain with swallowing (odynophagia): Discomfort or pain when food or liquid passes through the esophagus

Atypical and Extra-Esophageal Symptoms

Many people with acid reflux experience symptoms that may not immediately seem related to digestion. These occur when refluxed material reaches the throat, airways, or mouth, or when reflux triggers nerve reflexes that affect other areas of the body:

• Chronic cough: A persistent dry cough, especially at night, that does not respond to typical cough treatments
• Hoarseness: Voice changes, particularly morning hoarseness, caused by acid irritating the vocal cords
• Sore throat: Chronic throat discomfort or the sensation of a lump in the throat (globus sensation)
• Asthma-like symptoms: Wheezing or breathing difficulties, as reflux can trigger airway constriction
• Dental erosion: Wearing away of tooth enamel from repeated acid exposure, often noticed by dentists
• Excessive saliva: The body produces more saliva in response to acid in the esophagus (water brash)
• Bad breath: Persistent bad breath that does not improve with oral hygiene

What Causes Acid Reflux?

Acid reflux is caused by weakness or inappropriate relaxation of the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. Contributing factors include hiatal hernia, obesity, pregnancy, certain foods and medications, smoking, and eating habits such as large meals or eating before bedtime.

Understanding what causes acid reflux is essential for effective prevention and treatment. The condition results from a combination of anatomical, physiological, and behavioral factors that disrupt the normal barrier between the stomach and esophagus. While some factors cannot be changed, many can be modified through lifestyle changes.

The lower esophageal sphincter (LES) is the primary barrier preventing reflux. Normally, this ring of muscle remains closed except when swallowing. However, various factors can weaken this sphincter or cause it to relax inappropriately, allowing stomach contents to escape. Additionally, increased pressure within the abdomen can overcome the sphincter's resistance, forcing acid upward.

Hiatal Hernia

A hiatal hernia is one of the most significant anatomical factors contributing to acid reflux. The diaphragm is a large muscle separating the chest from the abdomen, with a small opening (hiatus) through which the esophagus passes. In a hiatal hernia, part of the stomach pushes up through this opening into the chest cavity.

This anatomical change weakens the barrier function of the lower esophageal sphincter and makes it easier for acid to reflux. Hiatal hernias are common, particularly in people over 50, and are often associated with obesity. While small hiatal hernias often cause no symptoms, larger ones frequently contribute to GERD. The risk of developing a hiatal hernia increases with age as the diaphragm muscle weakens.

Obesity and Increased Abdominal Pressure

Obesity is one of the strongest risk factors for acid reflux. Excess abdominal fat increases pressure within the abdomen, which pushes against the stomach and forces contents upward through the LES. Studies show that even modest weight gain can increase reflux symptoms, while weight loss often provides significant relief.

The relationship between obesity and GERD is so strong that weight loss is considered one of the most effective non-pharmacological treatments. Research indicates that a 10-15% reduction in body weight can dramatically reduce symptom frequency and severity. Additionally, obesity increases the risk of hiatal hernia, creating a double burden on the reflux barrier.

Pregnancy

Acid reflux is extremely common during pregnancy, affecting up to 80% of pregnant women at some point. Two main factors contribute to this: hormonal changes and physical pressure. During pregnancy, elevated progesterone levels relax smooth muscle throughout the body, including the lower esophageal sphincter. As the pregnancy progresses, the growing uterus increases abdominal pressure.

Symptoms typically worsen during the third trimester when the uterus is largest. The good news is that pregnancy-related GERD usually resolves after delivery. Treatment during pregnancy focuses on safe lifestyle modifications and medications that are approved for use during pregnancy, such as antacids and certain proton pump inhibitors.

Dietary and Lifestyle Factors

Certain foods, beverages, and eating habits can trigger or worsen acid reflux symptoms. These factors work through various mechanisms - some relax the LES, others increase acid production, and still others slow stomach emptying:

• Fatty and fried foods: Slow stomach emptying and relax the LES
• Spicy foods: Can irritate the esophageal lining
• Citrus fruits and tomatoes: Highly acidic and can worsen symptoms
• Chocolate: Contains methylxanthines that relax the LES
• Coffee and caffeinated beverages: Stimulate acid production
• Alcohol: Relaxes the LES and increases acid production
• Mint: Relaxes the LES despite being considered soothing
• Large meals: Distend the stomach and increase pressure
• Eating before bedtime: Lying down with a full stomach promotes reflux

Medications That Can Cause or Worsen Reflux

Several common medications can contribute to acid reflux by relaxing the LES, irritating the esophagus, or slowing stomach emptying. If you suspect your medication is contributing to symptoms, discuss alternatives with your healthcare provider:

• NSAIDs: Ibuprofen, naproxen, and aspirin can irritate the stomach and esophageal lining
• Calcium channel blockers: Used for blood pressure, these relax smooth muscle including the LES
• Sedatives and anti-anxiety medications: Can relax the LES
• Theophylline: Used for asthma, relaxes the LES
• Bisphosphonates: Used for osteoporosis, can irritate the esophagus
• Iron supplements: Can irritate the esophageal lining

What Can I Do to Manage Acid Reflux at Home?

Effective self-care for acid reflux includes elevating the head of your bed by 15-20 cm, avoiding eating 2-3 hours before bedtime, identifying and avoiding trigger foods, eating smaller meals, maintaining a healthy weight, quitting smoking, and wearing loose-fitting clothing. These lifestyle modifications are often sufficient to control mild symptoms.

Lifestyle modifications are the foundation of acid reflux management and should be tried before or alongside medication. For many people with mild to moderate symptoms, these changes alone can provide significant relief. Even those requiring medication often find that lifestyle modifications allow them to use lower doses or eventually discontinue treatment.

The key is to identify your personal triggers and make sustainable changes. Not all recommendations will apply equally to everyone - what triggers symptoms in one person may be well-tolerated by another. Keeping a symptom diary can help identify your specific triggers and track which interventions are most helpful.

Elevate the Head of Your Bed

One of the most effective lifestyle changes is elevating the head of your bed by 15-20 centimeters (6-8 inches). This uses gravity to help keep stomach acid in the stomach while you sleep. Simply use blocks or risers under the bedposts at the head of the bed, or use a specially designed wedge pillow.

It is important to elevate the entire upper body, not just the head. Using extra pillows to prop up your head can actually worsen symptoms by bending the body at the waist and increasing abdominal pressure. The elevation should be gradual from the waist up. Additionally, sleeping on your left side may help, as this positions the stomach below the esophagus.

Modify Your Eating Habits

When and how you eat is just as important as what you eat. Following these principles can significantly reduce reflux episodes:

• Do not eat within 2-3 hours of bedtime: This allows your stomach to empty before you lie down
• Eat smaller, more frequent meals: Large meals distend the stomach and increase reflux risk
• Eat slowly and chew thoroughly: This reduces air swallowing and promotes proper digestion
• Stay upright after eating: Avoid lying down, bending over, or exercising vigorously for at least two hours after meals
• Avoid tight clothing: Tight belts and waistbands increase abdominal pressure

Identify and Avoid Trigger Foods

While common trigger foods are well-documented, individual responses vary. Keep a food diary to identify your personal triggers. Common foods to evaluate include:

• Fatty and fried foods
• Spicy foods
• Citrus fruits and juices
• Tomatoes and tomato-based products
• Chocolate
• Coffee (even decaffeinated) and caffeinated beverages
• Carbonated drinks
• Alcohol
• Mint (including peppermint and spearmint)
• Garlic and onions

Maintain a Healthy Weight

If you are overweight, losing weight is one of the most effective ways to reduce acid reflux symptoms. Even a modest weight loss of 5-10% of body weight can produce noticeable improvements. The benefit is twofold: reduced abdominal pressure and decreased risk of hiatal hernia.

Stop Smoking

Smoking weakens the lower esophageal sphincter, increases acid production, reduces saliva production (which normally helps neutralize acid), and impairs the esophagus's ability to clear acid. Quitting smoking can improve symptoms within weeks. If you need help quitting, speak with your healthcare provider about cessation strategies and support programs.

When Should You See a Doctor for Acid Reflux?

See a doctor if you have heartburn more than twice weekly, difficulty swallowing, unintentional weight loss, persistent vomiting, or if over-the-counter medications do not help. Seek immediate emergency care for severe chest pain, especially with shortness of breath, jaw pain, or arm pain, as these could indicate a heart condition rather than heartburn.

While occasional heartburn is normal and can usually be managed at home, certain symptoms and situations require medical evaluation. Prompt attention to warning signs can prevent complications and ensure you receive appropriate treatment. It is also important to distinguish between heartburn and more serious conditions, particularly cardiac problems.

Many people self-treat acid reflux for years without seeing a doctor. While this is often appropriate for mild, occasional symptoms, prolonged self-treatment can mask underlying conditions or lead to complications. A medical evaluation establishes an accurate diagnosis and ensures appropriate treatment.

Symptoms That Require Medical Attention

Contact your healthcare provider for an appointment if you experience any of the following:

• Frequent symptoms: Heartburn occurring more than twice per week
• Symptoms affecting quality of life: Sleep disruption, interference with daily activities
• Difficulty swallowing: Feeling that food gets stuck or pain when swallowing
• Unintentional weight loss: Losing weight without trying
• Persistent nausea or vomiting: Especially if vomit appears like coffee grounds or contains blood
• New symptoms after age 50: New onset of heartburn in middle age or later
• Failure of over-the-counter treatment: Symptoms persist despite appropriate self-treatment
• Black or tarry stools: May indicate gastrointestinal bleeding

How Is Acid Reflux Diagnosed?

Acid reflux is often diagnosed based on symptoms and response to treatment. If symptoms persist or complications are suspected, diagnostic tests may include upper endoscopy (gastroscopy) to visualize the esophagus, 24-hour pH monitoring to measure acid exposure, and esophageal manometry to assess muscle function.

For most people with typical symptoms of heartburn and acid regurgitation, a diagnosis of GERD can be made based on symptoms alone. Often, a therapeutic trial of acid-suppressing medication serves as both a diagnostic and treatment approach - if symptoms improve significantly with medication, this supports the diagnosis. However, certain situations require more thorough investigation.

When Are Diagnostic Tests Needed?

Your doctor may recommend diagnostic testing if you have alarm symptoms (difficulty swallowing, weight loss, bleeding), atypical symptoms that do not clearly point to GERD, symptoms that persist despite treatment, or if you have had symptoms for many years without previous evaluation. Testing is also recommended before considering surgical treatment.

Upper Endoscopy (Gastroscopy)

Upper endoscopy is the most common test for evaluating GERD. A thin, flexible tube with a camera (endoscope) is passed through the mouth to examine the esophagus, stomach, and upper small intestine. This procedure allows direct visualization of any damage to the esophageal lining and enables tissue samples (biopsies) to be taken if needed.

Endoscopy can identify complications such as esophagitis (inflammation), strictures (narrowing), Barrett's esophagus (precancerous changes), or other conditions that may be causing symptoms. The procedure is typically performed under sedation and takes about 15-20 minutes. You will receive specific instructions about fasting before the procedure.

24-Hour pH Monitoring

If symptoms persist despite treatment or if the diagnosis is uncertain, 24-hour pH monitoring may be recommended. A thin catheter is passed through the nose into the esophagus (or a wireless capsule is attached to the esophageal wall), where it measures acid levels continuously for 24-48 hours. You record symptoms during this period, allowing correlation between acid exposure and symptoms.

This test is particularly useful for patients with atypical symptoms, those not responding to medication, and those being considered for surgery. It can definitively determine whether acid reflux is occurring and to what degree.

Esophageal Manometry

Esophageal manometry measures the strength and coordination of muscle contractions in the esophagus. A thin catheter is passed through the nose into the esophagus, and you are asked to swallow while the catheter measures pressure changes. This test evaluates how well the LES functions and whether the esophagus properly propels food toward the stomach.

Manometry is typically performed before anti-reflux surgery to ensure the esophagus has adequate muscle function and to rule out other conditions that might mimic GERD.

How Is Acid Reflux Treated?

Acid reflux treatment follows a stepwise approach: lifestyle modifications first, then over-the-counter medications (antacids, H2 blockers), and prescription medications (proton pump inhibitors) for more severe or persistent symptoms. PPIs are the most effective medications, providing symptom relief in over 90% of patients. Surgery is reserved for severe cases not responding to medication.

Treatment for acid reflux aims to relieve symptoms, heal any esophageal damage, and prevent complications. The approach is typically stepwise, starting with lifestyle modifications and progressing to medications if needed. Most people achieve good symptom control with a combination of lifestyle changes and over-the-counter or prescription medications.

The choice of treatment depends on symptom severity and frequency, presence of esophageal damage, response to previous treatments, patient preferences, and cost considerations. For many people, treatment is needed long-term, though some can eventually reduce or discontinue medication after implementing successful lifestyle changes.

Over-the-Counter Medications

Several types of medications are available without prescription for mild to moderate symptoms:

Antacids (such as calcium carbonate, magnesium hydroxide, aluminum hydroxide) neutralize stomach acid and provide rapid but short-lasting relief. They are best for occasional symptoms and can be taken as needed. However, they do not heal esophageal damage and should not be used long-term without medical supervision.

Alginates (such as sodium alginate) create a foam barrier on top of stomach contents, preventing reflux. They are particularly useful for symptoms occurring after meals or at bedtime and are safe for use during pregnancy.

H2 receptor blockers (such as famotidine) reduce acid production and provide longer-lasting relief than antacids. They take 30-60 minutes to work but provide relief for 6-12 hours. They are appropriate for frequent symptoms but less effective than PPIs for healing esophageal damage.

Proton Pump Inhibitors (PPIs)

Proton pump inhibitors are the most effective medications for treating acid reflux and GERD. They work by blocking the enzyme system that produces stomach acid, reducing acid production by up to 90%. Available options include omeprazole, esomeprazole, lansoprazole, pantoprazole, and rabeprazole.

PPIs are most effective when taken 30-60 minutes before the first meal of the day. They typically require several days to reach maximum effect but provide superior symptom relief and esophageal healing compared to other medications. For erosive esophagitis, they achieve healing in over 90% of patients.

While PPIs are generally safe, long-term use has been associated with potential concerns including reduced magnesium absorption, slightly increased risk of certain infections, and possible effects on bone density. These risks should be discussed with your healthcare provider, and the lowest effective dose should be used for the shortest necessary duration.

Surgical Treatment

Surgery is considered for patients with severe GERD that does not respond adequately to medications, those who cannot tolerate long-term medication, or those with complications such as large hiatal hernia. The most common procedure is fundoplication, in which the upper part of the stomach is wrapped around the lower esophagus to strengthen the LES.

Fundoplication can be performed laparoscopically (minimally invasive) in most cases, with recovery typically taking 2-4 weeks. Success rates are high, with most patients able to discontinue or significantly reduce medication use. However, some patients may develop difficulty swallowing, inability to vomit, or increased bloating after surgery.

What Are the Complications of Untreated Acid Reflux?

Chronic untreated GERD can lead to esophagitis (inflammation and erosion), esophageal strictures (narrowing), Barrett's esophagus (precancerous cell changes), and rarely, esophageal cancer. Regular monitoring and appropriate treatment can prevent most complications.

While occasional acid reflux is harmless, chronic uncontrolled GERD can lead to significant complications. The repeated exposure of the esophageal lining to stomach acid causes progressive damage that can be difficult to reverse. Fortunately, most complications are preventable with appropriate treatment.

Esophagitis

Esophagitis refers to inflammation and erosion of the esophageal lining caused by repeated acid exposure. Symptoms include painful swallowing, worsening heartburn, and occasionally bleeding. The condition is graded from mild (superficial erosions) to severe (extensive ulceration). Treatment with PPIs heals most cases within 4-8 weeks.

Esophageal Stricture

If chronic inflammation is left untreated, scar tissue can form, narrowing the esophagus (stricture). This causes progressive difficulty swallowing, particularly solid foods, and may lead to food getting stuck. Treatment involves dilation (stretching) of the narrowed area during endoscopy, which may need to be repeated, along with ongoing acid suppression to prevent recurrence.

Barrett's Esophagus

Barrett's esophagus is a condition in which the normal squamous cells lining the lower esophagus are replaced by intestinal-type cells - a process called metaplasia. This occurs as a response to chronic acid exposure and is considered a precancerous condition. It develops in approximately 10-15% of people with chronic GERD.

Barrett's esophagus increases the risk of esophageal adenocarcinoma, though the absolute risk remains relatively low (about 0.5% per year). Risk factors for Barrett's include long-standing GERD, male sex, age over 50, obesity, smoking, and family history. Patients with Barrett's require regular endoscopic surveillance to monitor for dysplasia (abnormal cell changes) that may precede cancer.

Acid Reflux During Pregnancy

Acid reflux affects up to 80% of pregnant women due to hormonal changes and increased abdominal pressure. Safe treatments during pregnancy include lifestyle modifications, antacids, alginates, and certain PPIs (omeprazole is considered safe). Symptoms typically resolve after delivery.

Pregnancy-related acid reflux is extremely common and results from the combined effects of hormonal changes and physical factors. Elevated progesterone levels relax the lower esophageal sphincter, while the growing uterus increases abdominal pressure. Symptoms typically worsen as pregnancy progresses, with the third trimester often being the most challenging.

Treatment during pregnancy prioritizes safety for both mother and baby. Lifestyle modifications are the first-line approach and include sleeping with the head elevated, eating smaller meals, avoiding trigger foods, and not eating close to bedtime. When medication is needed, antacids and alginates are considered safe throughout pregnancy. Among acid-suppressing medications, omeprazole has the most safety data and is generally considered acceptable when symptoms are severe.

Breastfeeding

Antacids and alginates are safe to use while breastfeeding. If stronger medication is needed, consult your healthcare provider about appropriate options. Most medications pass into breast milk in small amounts, but the benefit of treating significant symptoms usually outweighs the minimal risk to the infant.