While occasional heartburn is common, persistent reflux signals a significant health concern. Long-lasting heartburn indicates a failure of the body’s natural defense mechanisms. Understanding the causes and available treatments is the first step toward managing this condition, as chronic acid exposure can lead to serious complications.
Defining Chronic Reflux Symptoms
Occasional heartburn is typically a mild annoyance, but when acid reflux occurs two or more times per week, it is medically classified as Gastroesophageal Reflux Disease (GERD). The defining symptoms are a persistent heartburn sensation and the regurgitation of sour or bitter liquid back into the throat or mouth.
Chronic reflux can also manifest through extra-esophageal symptoms when stomach contents travel higher up into the airway. These manifestations include a chronic cough, persistent hoarseness, a sore throat, and the sensation of a lump in the throat (globus sensation). Long-term acid exposure can also contribute to dental erosion and the worsening of conditions like asthma.
Primary Underlying Causes of Persistent Acid Reflux
The primary physiological reason for persistent acid reflux is the malfunction of the Lower Esophageal Sphincter (LES), a ring of muscle between the esophagus and the stomach. Normally, the LES acts as a one-way valve, remaining tightly closed to prevent gastric contents from flowing back up. In chronic reflux, the LES is either generally weak (hypotonic) or experiences frequent, inappropriate relaxations.
A significant mechanical contributor is a hiatal hernia, where the upper part of the stomach bulges through the diaphragm into the chest cavity. This anatomical defect weakens the LES by disrupting the normal pressure gradient and support, increasing the likelihood of reflux episodes. The hernia can also trap acid in a small pouch, which easily refluxes into the esophagus.
Another factor is delayed gastric emptying, or gastroparesis. When the stomach takes too long to empty its contents, the increased volume and pressure can force stomach contents back up through a weakened LES.
Lifestyle Modifications to Minimize Symptoms
Behavioral and environmental adjustments can significantly reduce the frequency and severity of reflux episodes. One effective strategy is weight management, as excess abdominal weight increases internal pressure against the LES. Smoking cessation is also highly recommended because nicotine decreases the pressure of the LES, impairing its function.
Consuming smaller, more frequent meals helps prevent the stomach from becoming overly distended, reducing pressure on the sphincter. It is also effective to avoid lying down for at least two to three hours after eating, allowing gravity to assist in keeping food and acid in the stomach.
Common dietary culprits include fatty or fried foods, which delay gastric emptying, and acidic items like citrus fruits and tomatoes. Substances such as chocolate, caffeine, mint, and alcohol can also directly cause the LES to relax. For those who experience nighttime reflux, elevating the head of the bed by six to nine inches uses gravity to minimize acid backflow while sleeping.
Medical and Surgical Treatment Options
Pharmacological treatment for chronic reflux typically follows a stepwise progression, starting with over-the-counter options. Antacids, such as those containing calcium carbonate, offer rapid, temporary relief by neutralizing stomach acid. They are used for mild, intermittent symptoms but do not address LES dysfunction or heal esophageal damage.
The next step involves medications that reduce acid production, such as H2 receptor blockers (e.g., famotidine), which suppress acid secretion for a longer duration. For long-lasting and severe reflux, Proton Pump Inhibitors (PPIs) are the most potent class of acid-suppressing drugs. PPIs work by inhibiting the final step in stomach acid production, providing a profound and prolonged reduction in acid secretion that allows the esophageal lining to heal.
When symptoms are severe, unresponsive to medical therapy, or when a large hiatal hernia is present, surgical intervention may be considered. The standard procedure is fundoplication, most commonly the Nissen fundoplication, performed using minimally invasive laparoscopic techniques. During this operation, the surgeon wraps the upper part of the stomach (fundus) around the lower esophagus to create a new, tighter valve mechanism. Newer, minimally invasive procedures, such as the placement of a LINX device (a ring of magnetic beads) or Transoral Incisionless Fundoplication (TIF), are also available for select patients.