Acid reflux (heartburn) - triggers and treatments to ease

Certain foods

Many foods can cause acid build-up in the stomach. Particular culprits include spicy food, fatty food, tomatoes and tomato-based food, chocolate, and caffeine.

Pattern of eating

Reflux is more likely in those who skip meals, eat large meals, or have their meal shortly before bed.

Alcohol

Binge drinking or repeatedly drinking more than the maximum recommended limit may contribute to reflux.

Smoking

Both the chemicals and smoke itself can cause damage to the delicate lining of the esophagus, so whether you smoke or you live or work in smoky environments, stopping smoking and avoiding smokers around you can help with reflux symptoms.

Obesity

Anything that causes stomach contents to be squashed can push acid the wrong way past the esophageal sphincter, causing acid reflux. Obesity puts pressure on stomach contents via this mechanism.

Pregnancy

In a similar way, a growing pregnancy takes up more of the abdominal cavity, causing the stomach to be squashed and increasing the chance of acid reflux.

Hiatus hernia

The sack of the stomach usually sits below the diaphragm, the wall of muscle under your lungs that helps you breathe. Hiatus (hiatal) hernia is an anatomical variant where your stomach sack moves up through a narrow opening in the diaphragm into your chest. It’s quite common in those over 50, and if it’s not causing problems, it doesn’t need treatment. However, acid reflux or that burning feeling in the chest is a common symptom.

H. pylori bacteria

This is a bacteria that can set up residence in your stomach and produce much more acid, and its full name is Helicobacter pylori. Testing for it is fairly simple – a stool test, breath test, or tissue biopsy if you are having a camera investigation – and treating it is fairly simple, with a combination of antibiotics and acid suppressants.

Stress and anxiety

Most people are familiar with the feeling of “having a knot in your stomach” when you’re feeling worried, but with ongoing stress, anxiety or panic disorder, this adrenaline rush can cause a repeated surge of stomach acid that can develop into reflux. It’s important to address matters of the mind alongside the body, and physical and mental symptoms are always connected.

Medications

A number of medications can cause or exacerbate acid reflux. It’s important to be aware of overuse of some of the most common medications purchased from your pharmacy, like nonsteroidal anti-inflammatory drugs (NSAIDs) which include ibuprofen, naproxen, and aspirin, or those prescribed like diclofenac and indomethacin. Always take these at mealtime to reduce acid build-up.

Other medications prescribed by your doctor include those for high blood pressure, called beta-blockers, calcium channel blockers and alpha-blockers (also used to treat an enlarged prostate), steroid tablets to treat autoimmune or inflammatory disorders, anticholinergics to treat an overactive bladder, tricyclic antidepressants (an older type of medication), nitrates for angina, theophylline for asthma or chronic obstructive pulmonary disease (COPD), bisphosphonates for osteoporosis and benzodiazepines as short term pain relief or sedation in mental health disorders.

Cancer

Rarely, but importantly, cancer in the upper gastrointestinal tract (top of the digestive system) can cause reflux. This includes cancers of the esophagus, stomach, pancreas, gallbladder, and liver. While each manifest with slightly different symptoms, red flags to alert you to a serious problem include unintentional weight loss, poor appetite, progressive difficulty swallowing or regurgitating foods and liquids, and yellowing of the skin and eyes, called jaundice. Blood tests and liver function tests may show jaundice, and a cause for any iron deficiency anemia should also be sought.

Acid reflux can be treated with medications that work in different ways and provide either immediate or long-term relief. They can also be combined to maximize their effectiveness.

Antacids, such as Rolaids, neutralize excess acidity and provide immediate and short-term relief for a few hours. Antacids based on alginate, such as Gaviscon, can have a similar effect, but they also form a protective coating in the stomach, which can relieve symptoms for several hours.

Proton pump inhibitors (PPIs) work by shutting down the acid pump of the stomach. They are more effective than antacids in terms of duration of action. There are now some versions which are available to buy without a prescription, such as esomeprazole (Nexium), lansoprazole (Prevacid), and omeprazole (Prilosec). Higher dose versions may still need to be prescribed for some people. Common side effects of PPIs are generally mild and tolerable for most people but may include headaches, stomach aches, diarrhea, constipation, gas, and nausea.

H2 receptor blockers, a type of gut antihistamine, work differently than PPIs by reducing histamine's effect on the production of acid in the stomach. Cimetidine or famotidine are the most common active ingredients. As of August 2022, ranitidine (Zantac) has been removed from the market in the US due to safety concerns about levels of N-nitrosodimethylamine (NDMA), a nitrosamine impurity.

Acute acid reflux (symptoms lasting less than 2 weeks):

We recommend an antacid, such as Rolaids, or an alginate, such as Gaviscon suspension, to give immediate relief to neutralize acid reflux and heartburn from flare-ups or after a fatty or spicy meal.

For prevention or protection throughout the day:

We would suggest a PPI such as esomeprazole (Nexium), taken once every morning, to give all-day protection for the lining of the stomach. You should take it with water, but you don’t need to take it with food.

Acid reflux during pregnancy and breastfeeding:

Antacids such as Rolaids or Gaviscon are safe to take for short-term relief. The manufacturers of PPIs, such as Nexium, do not recommend use, so it may be worth a discussion with your doctor about the risks versus benefits of any particular medication.

Acid reflux in babies:

Antacids for infants can be purchased at the pharmacy; however, it is advisable to consult with a doctor before use, to confirm the diagnosis, as normal spitting of baby milk is often mistaken for reflux, and there may be other causes of symptoms for a doctor to consider.

Meal adjustments can make all the difference. Eat smaller meals, even if this means eating four times a day rather than the usual three. Make sure you stick to regular mealtimes and don’t skip them. Take your evening meal earlier, so you have at least three to four hours after eating before you go to bed (lying down on the sofa is also a bad idea).

Adapting your diet can help – start by cutting out any potential triggers in your usual intake. Once symptoms are under control, you can keep a diary and gradually re-introduce them one by one, but keep them in moderation and cut them out again if reflux returns.

Elevating the head of your bed by 6 to 8 inches may help, as it keeps your chest higher than your stomach, to allow gravity to work by keeping stomach contents where they should be.

Losing weight if you are overweight or obese (a Body Mass Index or BMI over 25) will help acid reflux and may even resolve it. This is best done with sensible low-calorie food options and a sustainable exercise program. If you also have a hiatus hernia, weight loss may ease the pressure pushing this up into the chest.

Stopping smoking can help in the long term for the esophagus to recover and regenerate newer, healthier cells. This is alongside all of the other health benefits a smoke-free existence provides.

Alcohol consumption similarly should be addressed by avoiding binge drinking and sticking to the recommended limit of 14 units per week. It’s a good idea to have at least two alcohol-free days in the week to rest your system.

Stress and anxiety may impact your life, and it’s worth addressing these with whatever measures you feel appropriate – for severe cases, this may require a discussion with your doctor or professional guidance from a psychologist. For everyone, introduce relaxation techniques, either formal such as mindfulness or body scanning, or other things that help you unwind – yoga, music, a brisk walk, or a good book - whatever can be easily incorporated into your daily routine.

Drinking peppermint tea is thought to aid digestion, and chamomile tea is thought to have soothing properties on the digestive tract, as well as helping to soothe an anxious mind. But you should avoid chamomile if you have a ragweed allergy. Ginger tea has long been touted as an aid to digestion and in alleviating stomach pain.

Licorice supplements are said to increase the production of mucus to coat the esophageal lining, thereby making it more resistant to the abrasion of stomach acid. Make sure any supplements contain deglycyrrhizinated licorice, as too much glycyrrhizin is thought to be harmful.

Loosen your belt and stand up straight after eating to help take the pressure off the esophageal sphincter while you digest your food, giving gravity a chance to keep stomach acid in the right place.

Chewing gum for about half an hour after eating has been shown in studies to reduce the stomach acid surge associated with mealtimes, as it increases saliva production, which helps to dilute the acid and coat the esophagus in a protective shield. Pick sugar-free gum to keep your teeth healthy.

Prebiotics and probiotics may help reduce stomach acid. The doctors at Healthwords think that nurturing the gut microbiome makes sense in building up a healthy balance of bacteria and protecting it from harmful bacteria like H. pylori. This may reduce the risk of acid build-up and reflux. More scientific data is needed but it is not known to be harmful. Try four weeks of daily prebiotic or probiotic drinks or supplements, or fermented milk drinks or kefir, and see if it helps symptoms.

If you’ve taken the suggested lifestyle measures, and you’ve tried over-the-counter medication for more than 1 to 2 weeks without sufficient improvement, or if your symptoms are having a serious impact on your daily life, it’s worth seeing your doctor.

If you think one of your prescribed medications could be contributing to acid reflux, before reducing or stopping this, discuss it with your doctor to agree on a plan together.

If you have any serious symptoms like unintentional weight loss, reduced appetite, difficulty swallowing, or regurgitation of food and drink, you should book an urgent appointment with your doctor.

The doctor will examine your abdomen, look for signs of anemia or jaundice, and they may weigh you. They may suggest a blood test and stool test. Depending on their findings, they may send you for further tests, such as a camera tube down the throat, called an endoscope, or they may suggest a scan. If they think cancer is a high probability, they will refer you urgently to a specialist gastrointestinal team.

Acid reflux is a very common problem that most people suffer with from time to time, and some people are prone to flare-ups. Most people can think of things in their recent lifestyle choices that they have slipped up on, and they need to rein these in. But it can help to have a few medications at home that they know will work for them.