by Stomach acid is incredibly strong – about 100 times stronger than vinegar – and when it gets into the wrong place, from the stomach to the esophagus, it is extremely unpleasant. Symptoms depend on how high it is and in what quantities, but range from 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 heartburn. Every time they lie down, their stomach acid goes into their throat.
According to the NHS, up to 20 per cent of adults in the UK suffer from recurrent acid reflux – called gastroesophageal reflux disease (GORD) – and around 10 million are prescribed proton pump inhibitors (PPIs), which reduce stomach acid by around 80 per cent. Research we have conducted at the Functional Gut Clinic suggests that in most cases it is “prescription first, never diagnosis.” More than half of the patients we surveyed have been taking PPIs for more than two years, and one in five have been taking PPIs for more than a decade. Very few had tests done to find the cause or a correct diagnosis made.
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Unfortunately, long-term PPI use comes with its own risks. Evolution has told us that it is important to have stomach acid, so acid reflux itself warns your body that there is a problem. It’s important to know what might be causing it, what measures you can take to get it under control, and when to investigate further.
First, rule out cancer
Acid reflux can be a symptom of esophageal cancer, but it can also be a cause if left untreated long enough. Whenever there is damage in the body, be it sunburn on the skin, smoke in the lungs, or acid in the esophagus leading to ulcers, bleeding, and inflammation, there is a chance that something will go wrong in the way cells repair themselves. Then the changes that can lead to cancer occur.
Esophageal cancer may show symptoms late, but if you experience acid reflux and heartburn, along with difficulty swallowing (you find eating slow or uncomfortable) or weight loss – especially if you have a family history of esophageal cancer – it is important to see your doctor for a correct diagnosis. This may require an endoscopy, which uses a long, thin tube with a camera to examine the inside of the body. A less invasive test uses a small sponge in a capsule on a thin 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 lab. It’s more like a swab of your esophagus.
Skip the burgers
If cancer is ruled out, there is a lot you can do before resorting to medication. The stomach is a bit like a pump. In order to function normally and everything to go in the right direction, valves at the top and bottom must be opened and closed at the right time.
A large roll of belly fat constantly weighing down your stomach like a dumbbell increases upward pressure on the flap. Large portions of food also increase pressure, and eating too many fatty foods slows down digestion significantly because the fat in the stomach has to be mixed with many different chemicals in order for it to be digested properly.
Rapid-onset reflux, which occurs quite soon after eating, is often caused by fatty meals such as takeaways, burgers, French fries or pastries. Late-onset reflux, which can occur four or five hours after eating, is more likely due to foods that are broken down in the lower intestine, such as garlic and onions, which can be difficult to digest.
Losing belly fat, reducing portion sizes, and changing your diet can have a big impact on acid reflux. A good “rescue diet” to pass through the system is white basmati rice, white fish and lightly cooked vegetables.
Taking medication – and the potential dangers of PPIs
Everything you eat and drink – and all the insects, bacteria and pathogens that come with it – is fought by stomach acid. It’s a bit like the disinfectant in a swimming pool. If you reduce this acid by 80 percent by taking PPIs for years, all pathogens can multiply and colonize the intestines. I see patients who started PPIs for heartburn, stayed on them, and then gradually experienced chronic symptoms such as bloating, diarrhea, or gastroenteritis. These are likely caused by a lack of stomach acid.
We need stomach acid for a variety of important functions – for example, it helps us absorb vitamin B12. If the lack of stomach acid has 10 or 12 different side effects, they add up over time. There are many reports linking long-term PPI use to kidney disease and Alzheimer’s disease.
If you want to make lifestyle changes to combat acid reflux but want to relieve symptoms in the meantime, start with over-the-counter medications like Gaviscon or Rennie, which neutralize stomach acid rather than reducing it. Taking it regularly after meals and before bed can provide you with additional protection.
If symptoms persist and a GP prescribes PPIs, they should be taken for a maximum of eight weeks.
The tests that can provide answers
If lifestyle changes haven’t helped and you’ve had an endoscopy for a visual check, physiological tests can show how everything is working. Esophageal manometry and pH testing actually provide objective answers. These tests show how strong the valves are, how well your swallowing muscles are working, and measure how much acid reflux you have over the course of a day. An electrogastrogram is a bit like an electrocardiogram, except that it involves the stomach rather than the heart and measures nerve and muscle function.
According to Hobson, physiological tests such as esophageal manometry and pH tests show how your insides are working – Heathcliff O’Malley
Are bacteria a problem?
It may also be worth testing for the presence of certain bacteria. About 60 percent of the patients we see with acid reflux and who are considering surgery test positive for small intestinal bacterial overgrowth. This is where insects multiply in the small intestine and begin to break down food before you can digest it, causing gas and bloating. This can be diagnosed using a hydrogen and methane breath test and is often treated with 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 is very common, increases with age, and many of us carry it without symptoms. However, when symptoms like reflux occur, it’s time to combat it with antibiotics, as the inflammation and cell damage can lead to precancerous cell changes.
When surgery is the only cure
In around one in 1,000 cases of reflux (and one in ten referred to our specialist clinics), surgery is the best option. If the hiatus – the opening in the diaphragm through which the esophagus passes – is larger than it should be, everything is too loose and more likely to move up and down at the wrong times. It may be a weakness that you were born with or that you developed as you got older.
Keyhole surgery under general anesthesia is the most common surgical procedure. This involves creating a new valve by wrapping the upper part of the stomach around the lower esophagus.
It’s worth noting that the vast majority of acid reflux diseases can be resolved through lifestyle changes. I don’t blame Deliveroo, but I’m sure the number of drivers lining up outside buildings just before bed to deliver a clandestine McDonald’s is 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
Lauren Jackson began her own research when she was struggling with heartburn
Earlier this year I started suffering from acid reflux and bloating. It happened every night and was so uncomfortable before bed that I could hardly lie down because it made it worse. There was massive belching.
I started buying Rennie and eliminating any foods that could be triggering the problem. I knew from experience that spicy foods and tomatoes could be difficult for me to digest. I did a really careful elimination diet, but that didn’t help. In August I also felt severe pain in my abdomen and so I went to see my family doctor.
This appointment began a long process in which it felt like I wasn’t being listened to. When the initial stool tests found no blood or signs of colon cancer, there was no further testing or testing at all. I was just diagnosed with irritable bowel syndrome and acid reflux and was asked to keep a food diary to understand my triggers. I had already done all of this and wanted answers.
I started doing my own research and after four visits to four GPs I asked for a test H. pyloria bacterial infection that can cause indigestion, pain or burning in the upper abdomen, bloating, and nausea. My GP didn’t seem convinced, but agreed to the test, which came back positive.
I was prescribed two powerful antibiotics and they helped – my symptoms have now subsided. If left untreated, the damage caused can occur H. pylori can lead to stomach cancer, so I’m glad I was able to advocate for it.
As told to Anna Moore
