Acidity and GERD: Symptoms, Triggers, Treatment and When to Get an Endoscopy

"Acidity" is one of the commonest complaints in clinics: a burning feeling in the chest or upper abdomen, sour taste in the mouth, bloating and belching. Most people experience it occasionally, but for some it becomes a long-term problem called gastro-oesophageal reflux disease (GERD). Understanding the causes and treatments helps you gain control, and also helps you recognise the rarer cases that need further investigation.

What happens in reflux

A ring of muscle (the lower oesophageal sphincter) at the lower end of the food pipe normally keeps stomach contents in. If it relaxes at the wrong time or is weak, stomach acid and food flow back into the oesophagus and irritate its lining. Factors include overeating, being overweight, pregnancy, a hiatus hernia, certain foods and medicines, and delayed stomach emptying.

Symptoms

Typical:

• Heartburn: burning pain behind the breastbone, often after meals or when lying down
• Regurgitation: sour or bitter fluid coming into the throat or mouth
• Belching, bloating and early fullness

Less typical:

• Chronic cough, especially at night
• Hoarse voice, sore throat or the feeling of a lump in the throat
• Asthma worsening
• Chest pain
• Dental erosion and bad breath

Common triggers

• Large or late meals, lying down within 2-3 hours of eating
• Spicy, oily or fried food, tomatoes and citrus, chocolate and mint
• Tea, coffee, fizzy drinks and alcohol
• Smoking, and chewing betel or tobacco
• Overweight and abdominal obesity. See our BMI calculator
• Tight clothing or heavy lifting
• Medicines: anti-inflammatory painkillers (diclofenac, ibuprofen, aspirin), some blood pressure medicines (calcium-channel blockers), nitrates, and some antibiotics, bisphosphonates and iron tablets
• Pregnancy
• Stress and poor sleep

Self-care measures

1. Eat smaller meals and avoid eating 2-3 hours before bed.
2. Raise the head of the bed by about 15 cm (6 inches) using blocks or a wedge pillow, instead of extra pillows only.
3. Identify and avoid your own triggers, since they differ from person to person.
4. Lose weight if overweight. A modest loss reduces reflux for many people. See how to lose weight safely.
5. Stop smoking and cut back alcohol and caffeine.
6. Avoid tight belts and clothes, and avoid bending straight after meals.
7. Chew food well, eat slowly and sit upright after meals.
8. Review your medicines with your doctor, and avoid unnecessary painkillers.
9. Try gentle exercise, such as walking after meals, but avoid vigorous exercise immediately after eating.

Medicines

• Antacids (such as aluminium, magnesium or calcium products) and alginates give quick, short-term relief for occasional heartburn.
• H2 blockers (famotidine, ranitidine alternatives) reduce acid production for a few hours and can be taken at night.
• Proton-pump inhibitors (PPIs): omeprazole, esomeprazole, pantoprazole, lansoprazole, rabeprazole. These are the most effective, and are taken 30-60 minutes before breakfast for 4-8 weeks, then reduced to the lowest effective dose. Long-term use can reduce absorption of B12, iron and magnesium, may raise infection and fracture risk slightly, so use only when needed.
• Prokinetics may help in selected people.
• Surgery or endoscopic treatment is considered for severe reflux that does not respond to medicines.

Stopping a PPI suddenly can cause temporary rebound acidity, so taper under advice.

H. pylori, ulcers and gastritis

Upper abdominal burning pain, often relieved or worsened by food, can come from gastritis or peptic ulcer. The main causes are infection with the bacterium Helicobacter pylori (common in South Asia) and NSAID painkillers. Testing is by breath, stool or endoscopy. Treatment is a 14-day course of acid suppression and two antibiotics, and the infection should be cleared and confirmed.

Alarm symptoms: see a doctor promptly

Do not self-treat for long if you have:

• Difficulty or pain swallowing
• Unintended weight loss
• Persistent vomiting, or vomiting blood
• Black, tarry stools or blood in stool
• Anaemia, tiredness and pallor
• A lump in the upper abdomen
• Symptoms that begin after age 45-55 for the first time
• Heartburn despite 4-8 weeks of treatment, or symptoms that keep returning
• Family history of stomach or oesophageal cancer

These need an upper GI endoscopy. Stomach cancer is common in East Asia, and countries such as Japan and South Korea offer endoscopic screening. People from high-risk regions or with family history should ask their doctor about checks.

Complications of long-term reflux

• Oesophagitis (inflammation) and ulcers
• Narrowing (stricture) of the oesophagus, causing swallowing difficulty
• Barrett's oesophagus, a change in the lining that slightly raises the risk of oesophageal cancer
• Dental erosion, chronic cough and voice problems

Is it really acidity?

Heart problems, gallstones, pancreatitis, lung disease and anxiety can mimic acidity. For chest discomfort, read chest pain or acidity, and call for emergency help if you have the heart attack warning signs in our heart attack symptoms guide.

Reflux in pregnancy, babies and children

Heartburn is common in pregnancy, and safe options include small meals, raising the head of the bed and antacids as advised by your doctor. Babies often bring up milk (posseting), which usually improves by 12-18 months. See a doctor if a baby is not gaining weight, refuses feeds or vomits forcefully.

When to see a doctor

See your doctor if you need antacids more than twice a week, symptoms disturb sleep, you have any alarm features above, or you are over 50 with new symptoms.

References

• American College of Gastroenterology: guidelines for the diagnosis and management of gastroesophageal reflux disease
• NICE guideline NG217: gastro-oesophageal reflux disease and dyspepsia in adults
• Maastricht VI/Florence consensus report on Helicobacter pylori management
• World Gastroenterology Organisation: global guideline on GERD