Hi everybody! It's Dr Renée and I'm back with my VLOG. This week i'm going to
talk to you about acid reflux. And it seems to me to be a massive problem
which is why I'm covering it. I see people with reflux in almost every
session that I work as a GP. So what is it? We all know that we have acid in our
stomach that our body uses to digest food, and that's exactly where it should
stay; in the stomach. But unfortunately in acid reflux it doesn't. It comes through
the sphincter or the elastic band which is the joint between your food pipe or
oesophagus and your stomach. And it moves up into the oesophagus and there it can
cause damage because it's in the wrong place. So depending on how often that
happens to you and how much acid comes through and also how far it travels up
the oesophagus, will dictate whether or not you have symptoms and how severe
they are. If it happens more than twice a week, by definition you have acid
reflux disease or gastro oesophageal reflux disease. Otherwise known as GORD.
In America they call it GERD because they don't spell oesophagus properly!
Just so if you're looking at this on the internet you know the difference is: GORD
and GERD are the same thing. So who gets it?
Well the stats vary dramatically, so we don't absolutely know, but estimates put
it about one in five people so 20%. That's a lot of people if you think
about it. And of course some people will be coping with it treating themselves
and therefore not coming forward and not being in the stats and some people won't
have symptoms, but that doesn't mean there isn't damage being done. So they
aren't coming forward either. So what are the causes? So hiatus hernia can cause
reflux and that's where a section of the stomach slides through that elastic band,
that sphincter, into the oesophagus. Being overweight puts lots of abdominal
pressure on your stomach and that can cause it too. Being pregnant, for the same
reason, you've got a baby in your tummy that's pushing up on my stomach. And this
is a really common pregnancy problem and quite often later in the pregnancy
when the baby's getting bigger. Lying down immediately after eating or
having a really large meal can be a problem. Or snacking before bedtime; same
kind of theory, that you're lying down after eating and your stomach's going to
work while you're sleeping. And then NSAIDs, non-steroidal anti-inflammatory
drugs or painkillers, that you and I know as ibuprofen, aspirin, diclofenac,
naproxen, to give you a few. These can really irritate the stomach and in
actual fact are the largest cause of stomach bleeds in the world, so that
could be a serious problem. And now, to ruin life completely, there are seven
foods and obviously they are foods that we really like in the main! So I'm about
to tell you about all the nice things that really irritate the stomach and
these seven food groups are a direct irritant to the stomach. So if you're
prone to acid reflux or gastritis then these will make it worse. So those are:
Tomatoes, spicy food, chocolate (yup chocolate).
Peppermint, and I know you're saying 'what peppermint's really good for the
stomach?' Well actually it's really good for the
colon but it's not so good for the stomach where it's a direct irritant.
Caffeine, so all of those coffees and teas I'm afraid need to go if you're
suffering. Alcohol, without question is a real problem, and smoking. So those are
the seven food groups you need to think about and the causes of acid reflux if
you're thinking about trying to cut things out and make yourself better. So
what are the symptoms? Well these are really varied and some people have some
of them. some have none, and some have every single one! So it's really difficult
sometimes to differentiate what's going on. And some of the symptoms are not
obvious as you'll see. So having heartburn is probably the most common
one when you have a burning sensation up the middle of your chest or behind your
sternum. Having difficulty swallowing or a lump in the throat is really quite
common. And talking at the throat you can actually get a hoarse voice from reflux.
So that would always mean investigating. Having asthma like symptoms, so
wheezing or coughing. But on the subject the cough, if you've had an irritating little
cough for months on end nobody's gets into the bottom of it, it
may well be reflux. And some treatment might send the cough away. Having a sore
throat all of the time. Chest pain. Tooth decay; so where the acid
is coming up and eroding the back of your teeth. Bad breath. Regurgitation.
Nausea. Burping. Hiccups that you can't get rid of. Shortness of breath. All of these
things, as odd as they may sound, can be down to acid reflux, and will need
treatment. So what's the risk of not treating acid reflux?
well oesophagitis is one of the main risks, where the acid just eats away at
your food pipe or oesophagus and actually causes erosions (or little holes). Or you
get ulcers and ulcers bleed and they can actually be fatal if they they
really do bleed. So both of those things are quite serious obviously. Barrett's
oesophagus is a risk, and we think that 10% of people (so one in ten) who have
regular acid reflux, get Barrett's oesophagus. And this is when the cells at
the bottom of the oesophagus change into a different type of cell type. And that's
a problem, it's a precancerous situation, so you can go on to get oesophageal
cancer if you've got Barrett's esophagus. So that's really serious. And then you
can get strictures, which is where the oesophagus actually gets webs of tissue
connecting one side to the other. And then you won't be able to swallow food
properly and you'll feel the food is sticking. So strictures are also really
serious. So I guess what I'm saying is it needs to be treated if you have it! So
those symptoms I mentioned were really vast and could always be other things. So
what else could it be, If it's not acid reflux? Well, your GP or your doctor,
should always move out any chest pain to make sure that it's not coming from your
heart, that's really important. They need to make sure that any cough or shortness
of breath or wheezing is not a respiratory problem, like asthma or
infection. And we also find hoarseness, so a husky voice, in some serious
oesophageal cancers. So those things have to be ruled out before we agree that it
is reflux and treat it as such. So how do you diagnose acid reflux? Well
normally people will go to the chemist and they'll get an over-the-counter remedy
like rennies or gaviscon (any of those). And if you do get symptoms, go and get those,
and it works that does more or less confirm that you are treating acid
reflux because the treatment is working. If it's not or it's not controlling it
completely, see your GP; really important. Your GP will take a really detailed
history, including a diet history. They'll weigh you, make sure you're not
overweight. They'll have a feel of your tummy. They'll do some tests: some blood tests, a
stool sample for Helicobacter pylori (and we'll talk about that later). They'll decide
if they can treat you or whether you need a referral. And then they will treat
you and they'll follow you up to see whether or not the treatment has worked.
So the management of acid reflux, initially is self-care, then it's trials
of treatment by your GP, and if none of that's working it's referral to a gastroenterologist
for them to investigate further. So let's talk about self-care because
these are the things that you can do at home before seeing a doctor. So weight
loss is really important. You need to have a BMI between 18.5 at 25 (and you
can find BMI calculators online). You need to avoid those 7 trigger foods I told
you about. As much as you like caffeine, it's a real irritant; go to decaf.
Cut alcohol out for a while. You may be able to get back to them later but you
need to let your stomach and oesophagus heal first. Have smaller meals, earlier
meals and don't have them within three to four hours of going to bed. Stop
smoking and manage stress and depression, because we have found that stress and
depression can also aggravate acid reflux disease. So what will your GP do
after they've taken their thorough history and decided that this is
probably reflux? Well they'll talk to you about lifestyle
and self-care that I've just talked about. They'll initially give you some
alginates. So that's gaviscon and those kind of things (peptac). And what these do is;
you take them after a meal and they actually sit over the food and acid in
your stomach and prevent it from rising up into your eosophagus. They might take a
stool sample for Helicobacter pylori. So you give a tiny bit of poo to your GP
receptionist (they have the best job in the world) and it sent off to the lab
to see whether or not you've got the bacteria Helicobacter living in your
stomach. And this can be a cause of acid reflux disease because these bacteria
burrow into the stomach wall and then they allow the acid in which causes the
problem. And what your GP may do alongside testing for Helicobacter
pylori is to give you a trial for a month of a PPI.
That's a proton pump inhibitor and you'll probably know them as omeprazole,
lansoprazole, oesoprazole. So these suppress the acid in the stomach
and if you try them for a month if that works all well and good.
And if that has worked, then they will work out with you a plan for the
future of lifestyle changes, plus a longer-term ppi, which gradually they
will try and wean off. And in the meantime, if your Helicobacter pylori
stool sample comes back as positive, they'll treat that. And that will be
treated with a week's course of one PPI and two antibiotics. But be warned, this
does not always get rid of the pain. They'll also do a medication review just to make
sure you're not taking any tablets which could be making the problem worse. So as
we've mentioned already, the NSAIDs will be looked at, but there are lots of other
medications. Things like alpha blockers, benzodiazepines,
beta blockers (so common blood pressure tablets), biphosphonates for your bones,
calcium channel blockers (again blood pressure), steroids,
nitrates, theophyllines. There's so many and I'll put a list of them afterwards so
you can have a look to see what you might be on that could be
irritating your stomach. So what if nothing works after that? What if you
have to go back to your GP and say 'I'm still in pain, I've still got these symptoms'.
So the GP should revisit everything again and make sure there's not an
alternative diagnosis, so is it your heart, is it your liver, is it asthma etc
They might add another medication in, an H2 receptor antagonist, something like
ranitidine and see if that helps, which again suppresses acid. But if all
else fails they will actually send you to a gastroenterologist, or directly for
an endoscopy before a gastroenterologist, to see what's going on. It's important to
know that 50 to 70 percent of endoscopy's are normal. So the camera goes down
and can't find anything. And in the rest of the cases they can find gastritis (so
an irritation of the stomach wall), they'll find Barrett's oesophagus which
we spoke about earlier, or they'll find an ulcer. So what about taking PPI's
long-term? Is that a good idea? And this is a question we get asked all the time.
Well the aim should always be, to be on the lowest possible dose of a PPI. And if
possible wean off. And sometimes even with all of the lifestyle changes it's
not possible. But in most cases if those lifestyle changes are really adhered to
then it should be possible in the longer term. What are the risks of a long term PPI?
Well there are risks and this is important. So you're at a higher risk of
infection, so you have a lower threshold for getting pneumonia. Small
intestine bacterial overgrowth (SIBO) is more common in people taking a PPI.
Infection with salmonella and campylobacter, which causes diarrhoea and
tummy upsets. And C. difficile, which is one of the superbugs is also more common in people that take
PPI's. You could also become deficient in some essential minerals and vitamins. So calcium, iron, magnesium and
vitamin b12 for example, so that's important. Kidney disease has been
reported, as has osteoporosis. There's also been some studies recently
about a connection between PPI's and stomach cancer, and I know from the radio
show that this is a cause of distress to people who feel
they need them but obviously don't want the risk of stomach cancer. So I just
wanted to unpick that a little bit. So the study was from Hong Kong and it was
63,000 people, so it was quite a big study. But all of these people had been
treated for Helicobacter pylori and had reflux disease. So what the study said
was that those taking a PPI long term were twice as likely to get stomach
cancer within seven to eight years. Now look at that sensibly; it's still tiny.
let's stress that. Stomach cancer is really very rare; about four cases per
10,000. So even if you double that, it's still minute. so the chances of you
getting stomach cancer in your lifetime are miniscule. And there are risk factors
that put you at higher risk for it. So we know that Helicobacter pylori is
linked to an increase in stomach cancer and all of these people had been
treated for it. So the study was already skewed in that direction. The study
didn't prove for sure that PPI was the cause, there was an association.
It wasn't adjusted for other risks for stomach cancer like smoking and alcohol.
And all of the patients in the study were Asian, and we know that there is a
higher risk of stomach cancer in Asian communities. So I don't think this
particular study was very relevant to the UK. I think it's interesting but
I don't think it should worry you in terms of an increase in your risk; if
you need a PPI you need one. So that leads us on to the next question
beautifully, which is, do I take one or not when I've got acid reflux? So the
answer to that is quite straightforward. If you have complicated gastro
oesophageal reflux disease; so if you have an ulcer, Barrett's oesophagus then yes the
benefits of a PPI outweigh the risk. If you have uncomplicated disease
try and use the lowest dose possible and stop when you can by using lifestyle
changes to try and treat the underlying problem. So that's the guidance that I
would give.
I always try and look at natural remedies,
as you know. So I've done that today and all of these are alongside self care, I
guess they are self care. So managing your stress is really important then we know
that that's important and it does have an impact. Wear looser clothing around
your tummy so you're not pushing up on the stomach and putting pressure on.
Raise the head of your bed so that you sleep head higher than feet so that the
acid actually goes down rather than up. Aloe vera juice has been mentioned as a
solution but it is a laxative so be careful, because you don't want to
replace one problem with another. Ginger and fennel tea have been mentioned as a
solution, as has baking soda in water although I think that's pretty
disgusting to drink, so I'm not sure if I could actually do it, but it's a
suggestion. And then regular yogurts and probiotics. So we know how important the
gut microme is in almost every disease process, so I'm sure that won't do any
harm, and they will help. So in conclusion, these food triggers,
these seven foods, are really important and I go over that with all of my
patients. And just to reiterate; tomatoes, spicy food, peppermints,
chocolates, smoking, alcohol and caffeine. Cut those out if you have a problem. You
may not have to do it for a long time. You may have to do it for three to six
months to let the stomach heal and then you might be able to go back. You can
replace the caffeine with decaffeinated, so that's fine, don't think you have
to get rid of coffee or tea, just go for decaffeinated!
Lose weight if you can. Just a five to ten percent weight loss may help the
problem significantly. But these things don't work for everyone, some people
really suffer. So if they're not working for you go and see your GP, get checked
out and there are treatments and tests that they can do and hopefully solve the
problem. So that's my VLOG today. I hope it's helped. I'll put the information
that I said, including the seven foods, in the comments afterwards. Please let me
know what you think, ask me any questions and please suggest any topics
for the future; this one was suggested on the radio and that's why I've done it
today, and I'm more than happy to go with what you need. Take care for now, bye!