When is acid reflux considered to be a serious medical problem?

The unpleasant symptoms of acid reflux can be a barrier to enjoying favourite foods or drinks and good quality sleep. In this second article of Professor Stuart Bloom’s series on the condition, the renowned consultant gastroenterologist discusses the available treatment options for acid reflux and their pros and cons. He additionally offers expert insight on some more serious complications associated with acid reflux.

When is acid reflux considered to be a serious medical problem?

If the patient is experiencing very troublesome symptoms and disruption to daily life, it can be considered a serious problem. There is actually a very poor correlation between the severity of reflux as determined by laboratory measurement or endoscopy and a patient’s own experience of symptoms; the two don’t always go together.

When we decide to do an endoscopy, we can often grade the severity of inflammation. We may do this for a variety of reasons, for instance if the reflux has been going on for some time, if the patient is over a certain age or if the symptoms fail to respond to simple medication. 

Can acid reflux be a sign of a more serious medical issue?

Yes, acid reflux might sometimes signify significant inflammation at the lower end of the oesophagus. In some cases, the body tries to resolve this in the normal healing process which can cause scar tissue to form that narrows the oesophagus into what we call a stricture. This can impede the flow of solids and in severe cases, even liquids and so requires treatment.

Another complication of acid reflux is the development of change in the lining of the lower oesophagus from its usual squamous type into a columnar type in an attempt to adapt to the acid's presence. This is called Barrett’s oesophagus and is significant because, in rare cases, this can progress to more serious conditions including oesophageal cancer.

What treatment is available for acid reflux?

With regard to drug treatment, the simplest medication for acid reflux is antacids which can be bought over the counter and come in a range of forms such as Gaviscon or other proprietary antacids. These can be very helpful in relieving symptoms and can be taken in more or less unlimited dosages.

Traditionally, histamine receptor antagonists, also known as H2-blockers, were widely used as a next step in medication for acid reflux. Ranitidine, a type of H2-blocker, was the go-to medication for many people but it has now been withdrawn from the market. This was due to concerns about the coating of the drug, rather than the drug itself. Nowadays, the only H2-blocker which is widely available is a drug called Famotidine taken in doses of 20mg a day. This is particularly effective for night time reflux but is not as strong as Proton-pump inhibitors.

There are four Proton-pump inhibitors currently on sale in the UK market, including Omeprazole, Lansoprazole, Rabeprazole and Pantoprazole which are all effective in treating reflux. Although there may be variation in how they are prescribed, these tablets can all be taken for an initial period of six weeks before any further investigation is required. Once significant complications have been excluded, they can be taken for long periods of time.

There have been considerable concerns expressed about long term administration of Proton-pump inhibitors and the topic is quite complex. In short, however, a low dose, maintenance Proton-pump inhibitor can provide significant relief against gastric acid reflux for many years. This may not necessarily be taken on a continuous basis but can be used as required and even as a preventative measure before eating to relieve symptoms, particularly if they are going out for a special meal, for example.

Is surgery ever required to treat acid reflux?

Surgery for acid reflux usually involves an operation called a fundoplication where the stomach is lifted up to wrap around the lower end of the oesophagus to strengthen the lower oesophageal sphincter. This traditional approach to surgery is now being extended by a number of endoscopic techniques where a variety of mechanisms can be employed to improve the functioning of the lower oesophageal sphincter. However, it should be noted that these endoscopic techniques are still in the early development phase and we await long term outcomes.

Surgery is occasionally offered to patients with significant reflux, either because of complications such as overflow of acid reflux into the lungs or because of a failure to respond to treatment by medication. The biggest problem with this type of surgery is that it can result in a significant complication rate. The most common complications are:

• food sticking on its way down because the repair surgery tightens the lower oesophageal sphincter
• a failure to be able to burp, belch and release gas from the stomach which predisposes to bloating

Consequently, the decision to opt for surgery is a very finely balanced and needs to be considered jointly between physician, surgeon and patient.

If you are seeking treatment for acid reflux and wish to discuss your options, you can book a consultation with Professor Bloom by visiting his Top Doctors profile.