Reflux disease

Dr. med. Julia Schwarz is a freelance writer in the medical department.

More about the experts All content is checked by medical journalists.

Reflux disease (gastro-oesophageal reflux disease) is an abnormally increased reflux of acidic stomach contents into the esophagus. The symptoms of the disease affect around 20 to 30 million Europeans every day. People with reflux disease have heartburn and pain behind the sternum, often worse when lying down. Reflux disease can be reliably diagnosed with the help of 24-hour pH-metry. Medication or a change in diet relieve the symptoms. Here you can read everything you need to know about reflux disease.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. K21

Reflux disease: description

It is actually quite normal during the day that gastric juice occasionally flows back into the esophagus. In gastroesophageal reflux disease, however, the amount of acidic gastric juice that rises back up into the esophagus is abnormally increased. Stomach acid is a good thing if it stays in the stomach. There, the low pH value between 1 and 4 helps with the digestive process and kills harmful substances. The stomach is also specially protected from the acid. Not so the esophagus - its mucous membrane is not resistant enough and is attacked by the acid.

On the way from the mouth to the stomach, the esophagus runs through a small opening in the diaphragm. This is usually the cause of reflux disease: The lower sphincter muscles, which actually ensure that the esophagus closes again after swallowing the food, are dysfunctional. Reflux disease causes the lower esophageal sphincter muscle (lower esophageal sphincter) no longer to seal completely when lying down or when bending over and the hydrochloric acid from the gastric juice comes into contact with the esophageal mucosa. If this happens over a long period of time, the lining of the esophagus is damaged. This can lead to a painful inflammation with changes in the mucous membrane (reflux esophagitis).

Reflux Disease: Who Does It Affect?

In the western population, ten to twenty percent of people suffer from reflux disease. It is therefore a very common disease that affects women more often than men. The incidence of reflux disease increases with age, but in rare cases it also affects babies and toddlers.

Reflux disease: forms

Differentiation between NERD and ERD

If there is a reflux without changes in the mucous membrane, one speaks of a non-erosive gastroesophageal reflux disease (NERD). NERD make up about 60 percent of all people with gastroesophageal reflux disease. If, on the other hand, changes in the mucous membrane can be detected in a tissue sample from the esophageal specimen, this is referred to as erosive reflux disease (ERD).

Differentiation between primary and secondary reflux disease

There are also two different forms of reflux disease: primary and secondary reflux disease. Both show either a loss of function of the lower esophageal sphincter muscle (esophageal sphincter) and / or restricted mobility of the esophagus. This means that the body's own cleaning mechanism of the esophagus is impaired. Normally it eliminates stomach acid through its own movements (peristalsis). If the mobility is restricted, however, the contact time of the acid with the esophageal mucosa is increased and damage occurs more easily.

Primary Reflux Disease

Primary gastroesophageal reflux disease is by far the most common form of reflux disease. Primary means that no clear cause has been found for this. What is certain, however, is that the lower esophageal sphincter relaxes outside of the regular swallowing act and the esophagus no longer seals sufficiently against the stomach. There are several factors that contribute to the development of primary reflux disease. These include obesity, certain eating habits (see causes and risk factors), a weakening of the diaphragm or inadequate protective mechanisms of the esophagus (restricted movement or reduced saliva production).

Secondary reflux disease

Secondary gastroesophageal reflux occurs as a result of a known physical change - it is less common than primary reflux disease. For example, in 50 percent of women in the last trimester of pregnancy, pregnancy leads to reflux disease due to the increase in pressure in the abdomen. Furthermore, diseases of the digestive tract that lead to an anatomical change in the esophagus or the stomach can trigger secondary reflux disease.

Reflux disease: symptoms

You can read everything you need to know about the typical signs of reflux disease under Reflux symptoms.

Reflux disease: causes and risk factors

In most cases, reflux disease is caused by a relaxation of the lower esophageal sphincter muscle (lower esophageal sphincter). Outside of the act of swallowing, the sphincter no longer seals the esophagus sufficiently against the stomach. Especially when lying down and bending down, acidic stomach contents enter the esophagus and irritate the mucous membrane. In other cases, the mobility of the esophagus is reduced, which means that the esophagus cannot clean itself sufficiently and the stomach acid has prolonged contact with the mucous membrane. The corrosive stomach acid damages the mucous membrane, which in many cases causes burning pain (heartburn).

Primary Reflux Disease - Causes

The exact mechanism that leads to repeated leakage of gastric contents in primary reflux disease has not yet been fully clarified. However, there are various factors that cause increased gastric acid production and relaxation of the esophageal sphincter, thereby promoting reflux disease.

Primary Reflux Disease - Diet

Diet has a major impact on gastroesophageal reflux disease. Certain foods irritate the lining and stimulate the stomach to produce more acid. On the one hand, coffee, foods that are too fatty or too sweet and alcohol irritate the mucous membrane of the esophagus and promote inflammation. In addition, caffeine, nicotine as well as stress and tension stimulate gastric acid production. Alcohol also inhibits the mobility of the lower esophageal sphincter, which can also cause reflux disease to progress.

Primary reflux disease - diaphragmatic weakness, diaphragmatic hernia, enlarged His angle

90 percent of those affected by reflux disease also suffer from a diaphragmatic hernia (axial hiatal hernia). The diaphragm is a large respiratory muscle that separates the chest from the abdomen. The three openings for the esophagus, the main artery (aorta) and the vena cava are natural weak points in the muscle. With a diaphragmatic hernia, the stomach pushes through the diaphragmatic opening of the esophagus up into the chest, whereupon the lower esophageal sphincter is stretched and promotes gastroesophageal reflux. While most patients with reflux disease have an axial hiatal hernia, not every patient has reflux disease. According to experts, a hiatal hernia is therefore not the direct cause of reflux disease.

Another factor that promotes reflux disease is an enlarged "His angle". The angle of His is the angle between the mouth of the esophagus and the stomach and the top of the stomach. Usually it is around 50 to 60 degrees. If it is larger than 60 degrees, acidic gastric juice can flow back into the esophagus more easily.

Secondary reflux disease - causes

In secondary reflux disease, the weakness of the esophagus muscles is caused by another disease or a change in the body. The reasons for this are usually an increase in pressure in the abdomen or anatomical changes in the surrounding structures.

pregnancy

In 50 percent of women, pregnancy means that the increased pressure in the abdomen makes it easier for the stomach contents to flow back into the esophagus. The further the pregnancy progresses and the size of the abdomen increases, the more likely it is that reflux disease occurs. The esophageal sphincter no longer seals properly and the acidic stomach contents increasingly enter the esophagus. In most women, reflux disease resolves on its own after giving birth.

Organic diseases

There are various organic diseases that can cause the stomach outlet to narrow (pyloric stenosis). The stomach contents are not transported into the small intestine, but back up. A stomach tumor can also obstruct the outflow of stomach contents. When the stomach contents back up, the pressure increases and the stomach contents can more easily pass into the esophagus and lead to reflux symptoms.

In addition, a rare hardening of the connective tissue in the esophagus, the systemic scleroderma, can lead to a lack of mobility of the esophageal muscles and thus to impaired self-cleaning of the esophagus. This is also the case with so-called achalasia, in which permanent tension in the lower esophageal sphincter prevents normal mobility of the esophagus.

Reflux disease: examinations and diagnosis

The right person to contact if you suspect a reflux disease is your general practitioner or a specialist in internal medicine and gastroenterology. With a detailed description of your symptoms and any previous illnesses, you provide the doctor with important information about your current state of health (anamnesis interview). In order to get an exact picture of your illness, the doctor could ask you the following questions:

Are You Suffering From Heartburn?
Do the symptoms increase when lying down or when bending over?
Do you have to eruct more often?
Do you suffer from a feeling of pressure in your throat?
Do you have difficulty swallowing?
Have you noticed a dry cough that occurs more often at night?
Have you noticed bad breath often?
Do you have previous illnesses in your esophagus or stomach?
Do you take medicine?
Do you drink alcohol, coffee, smoke and what is your diet?

The doctor will usually also perform a physical examination to rule out other causes for your symptoms. He will ask you to free your upper body. By listening to the heart with a stethoscope, he can gain clues as to whether, for example, a feeling of pressure in the chest is triggered by a disease of the heart and not by reflux disease. The doctor may also take a look at your mouth and throat. Because a fungal infection can cause similar symptoms, for example. A gastroscopy or a long-term pH measurement over 24 hours is always necessary for a reliable diagnosis of reflux disease.

Further investigations

Gastroscopy (esophago-gastro-duodenography)

During a gastroscopy, the doctor can look at the upper digestive tract with the help of a camera that is inserted into a tube (endoscope). The patient is not allowed to eat or drink anything for six hours before the examination so that the examiner has a clear view of the tissue. To do this, the patient lies on their left side and, if desired, is briefly anesthetized. A mouthpiece between the teeth prevents the patient from accidentally biting the endoscope. The doctor then pushes the tube through the esophagus into the stomach and into the small intestine. With the help of a gastroscopy, he can assess whether and to what extent the reflux disease has already damaged the mucous membrane. Furthermore, a possible cause of the reflux disease can be searched for in the stomach. The doctor also takes tissue samples from abnormal areas of the mucous membrane. These are then assessed under a microscope by a pathologist.

Long-term pH-metry (over 24 hours)

Measuring the pH value in the esophagus over a period of 24 hours is the standard method for reliably diagnosing reflux disease. Long-term pH-metry is particularly important if the gastroscopy did not reveal any evidence of damage to the mucous membrane.

With long-term pH-metry, a thin tube (probe) is pushed through the nose into the esophagus (and possibly up to the stomach). The probe measures the pH of the stomach and esophagus for a day and night. A throat anesthetic can be helpful if the gag reflex is strong. It is important that any acid-inhibiting medication taken is discontinued at least 72 hours before the examination in order to avoid false negative results. In some cases, an X-ray is taken to ensure that the probe is in the correct position. The probe is connected to a small recording device that the patient carries with him for 24 hours. In addition, the patient keeps a diary in which he notes the meals and activities of the day. The recordings are evaluated together with the patient's notes. Reflux disease is confirmed if a pH value of four or less is measured in the esophagus for more than eight percent of the measured time.

Reflux disease: treatment

Reflux disease can be treated. General measures, as well as a change in eating habits and lifestyle, already lead to a significant alleviation of symptoms for many of those affected. Medicinal reflux treatment helps 90 percent of those affected. If the reflux disease is particularly severe, surgery can also help.

General measures

Wearing trousers that are too tight should be avoided if you have reflux disease. This can increase the pressure in the abdomen, making stomach contents easier to enter the esophagus. It also helps most patients if they sleep at night with their upper body slightly elevated and lying on their left side. Gravity is used to counteract the reflux naturally. Physical activity and, above all, weight loss if you are overweight are particularly beneficial in reducing the pressure in the abdomen and stimulating digestion.

Reflux Diet

Those affected often suffer from digestive disorders as part of their reflux disease. On the other hand, diets high in protein are often well tolerated. Because the proteins stimulate the stomach to produce the peptide hormone gastrin.The gastrin increases the muscle tension of the sphincter to the esophagus, which then closes better again. On the other hand, gastrin increases gastric acid production. Choosing the right food and amount of food can also have a positive effect on reflux disease: Small, low-carbohydrate and low-fat portions should be preferred. Meals should also be taken some time before going to bed so that most of the stomach contents have already been transferred to the small intestine when you go to bed.

Avoid harmful substances

Consumption of alcohol should definitely be avoided. On the one hand, alcohol directly damages the mucous membrane. On the other hand, alcohol causes the lower esophageal sphincter to relax. It is therefore a very important factor influencing reflux disease. The effect of coffee on reflux disease, on the other hand, is controversial. On the one hand, caffeine stimulates the stomach to produce gastric acid, which can further irritate the mucous membrane. On the other hand, caffeine also increases the production of gastrin, which means that the esophageal sphincter closes better. Just try out how well and how much coffee you can take. You should refrain from smoking. Smoking, and nicotine in particular, leads to excessive gastric acid production and numerous other negative effects on the entire body.

Inhibit acid production with medication

So-called proton pump inhibitors (PPIs) are the first choice drug in reflux therapy. These substances include, for example, omeprazole or pantoprazole. Proton pump inhibitors are generally considered to be well tolerated and 90 percent of those affected no longer have any symptoms. The intake of proton pump inhibitors should be started in high doses and then reduced as the process progresses. However, upon complete discontinuation, 50 percent of patients experience a recurrence of the symptoms. There is also the option of promoting stomach movements in the direction of the small intestine with the active ingredient domperidone. This improves the outflow of gastric acid and possibly improves the symptoms of reflux. The use of other gastric acid-reducing drugs (so-called antacids) can also be useful against excessive gastric acid production.

Reflux surgery

If the reflux disease is very advanced and cannot be treated with medication, surgery may be necessary. In the so-called "Nissen fundoplication" surgical technique, a cuff is formed from the upper part of the stomach, placed around the lower end of the esophagus and sewn in place. The cuff serves as a stabilizer for the esophageal sphincter. The operation can bring some complications and should therefore only be carried out if, for example, no improvement can be achieved despite proton pump inhibitors or antacids. Even if gastric juice has already flowed back into the trachea (aspiration), an operation should be discussed, as this can otherwise lead to pneumonia. In addition to the Nissen fundoplication, other surgical procedures such as hiatoplasty and fundopexy are also available.

Reflux Disease Home Remedies

Many people swear by the use of substances that neutralize the acid (antacids) for heartburn. This includes, for example, the so-called Bullrich salt. This consists of 100 percent sodium hydrogen carbonate, which balances the stomach acid. Bullrich's salt often helps against acute heartburn, but it has been proven to really stimulate acid production in the stomach. So it is by no means a remedy that one should constantly use against heartburn. The commonly used proton pump inhibitors are better tolerated.

Another home remedy for reflux is chamomile tea. This has anti-inflammatory properties and can help reduce stomach acid production. Naturopathic doctors recommend a chamomile tea roll cure in particular. First you drink some chamomile tea, then you lie on your back for five minutes. Then you drink a few sips of chamomile tea again and lie on your left side for five minutes. According to this principle, proceed with the prone and right lateral position. The chamomile tea roll cure takes about 20 minutes in total. The purpose of the roll cure is to wet the stomach wall as completely as possible with chamomile tea.

Reflux disease: disease course and prognosis

The therapies listed reduce the symptoms of most patients. If left untreated, however, permanent exposure to acid can lead to various complications.

Gastroesophageal reflux disease with esophagitis

Esophagitis is an inflammation of the gullet (esophagus), triggered by the increased acid contact in the gastroscopy with changes in the mucous membrane. Typically, the inflamed mucous membrane is red and swollen. If a gastroscopy and the tissue samples taken do not reveal any changes in the mucous membrane, it is a non-erosive gastroesophageal reflux (NERD).

Barrett's esophagus

The lining of the esophagus is not made for contact with stomach acid. As a result of high acid exposure and recurring inflammation, the mucous membrane changes in some patients and adapts to constant contact with gastric acid. The tissue is rebuilt and then contains more resilient cells (columnar epithelium) with mucus-producing cells (goblet cells), which are more resistant to gastric acid. This cell remodeling (metaplasia) of the esophagus is known as Barrett's esophagus or Barrett's syndrome. However, the cell changes increase the risk of a malignant tumor (adenocarcinoma) of the esophagus. Approximately one in ten patients with Barrett's esophagus will develop esophageal cancer. If Barrett's esophagus is known, consequent reflux treatment with regular check-ups should be carried out.

Reflux Disease - Other Complications

There is a risk of stomach acid entering the windpipe. The caustic properties can irritate the larynx, which can lead to inflammation (laryngitis). The patients often suffer from hoarseness. "Inhaling" stomach acid can also cause a chronic, irritable cough. Acid-related damage to the lungs also makes it easier for pneumonia to develop (aspiration pneumonia). Damage to the lining of the esophagus can also lead to chronic bleeding, which can lead to anemia. The reflux disease should therefore always be treated in order to avoid the aforementioned consequential damage.

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