How is acid reflux treated?
Dr. Tan Chi Chiu discusses treatment options for patients with acid reflux symptoms
When faced with a patient with reflux symptoms how we approach treatment depends on how severe the symptoms are and how old the patient is, says Dr. Tan. As with all diseases in the digestive system the older a patient is the more we would have to exclude serious disease, he adds.
For patients who are young and who have typical reflux symptoms we might try using anti-reflux medication, typically an acid inhibitor called a proton pump inhibitor. These drugs when given over a week or two would be like a therapeutic test as to whether it is indeed acid reflux because if it is then the patient will report that they feel a lot better. If the patient does not improve or the symptoms come back again then we would be prompted to do more tests.
The tests we might do to evaluate reflux symptoms include blood tests, it may include some imaging, such as an ultrasound or even a CT scan depending on the symptoms, or an MRI, and it could certainly include a gastroscopy, which is an endoscopic examination of the upper digestive system. This is the most direct way through which we can look at the lining of the oesophagus to see whether or not there is evidence of inflammation, erosions, ulcerations or perhaps even scarring. We will also be looking for symptoms of Barrett’s Oesophagus, which is a kind of cell that develops after prolonged stimulation by acid and it is a risk factor for adenocarcinoma, which is cancer of the lower oesophagus.
Whether we proceed to gastroscopy in the first instance depends on the patient profile. If it is a young patient with very typical symptoms of reflux we might content ourselves with a therapeutic trial of medicines, such as with a proton pump inhibitor, which prevents or slows down acid production in the stomach. If the patient gets better then we can perhaps say that this is most likely due to acid reflux. Some patients don’t get better with this treatment, some patients have symptoms that quickly come back again and so that may prompt us to do further tests such as a gastroscopy.
In slightly older patients, perhaps 45 years and above, where the risk of cancer is higher we may be prompted to do an endoscopy alongside blood and imaging tests so as to give some reassurance to the patient that nothing is seriously wrong. Whether the patient has non-erosive reflux or erosive oesophagitis with or without complications, the medical treatment of these is fairly similar. The key drug is something called a proton pump inhibitor. It reduces acid secretion from the stomach so that the gastric liquid, whatever it is that comes into the oesophagus, is not as highly acidic as it used to be. This can certainly cure oesophagitis and prevent complications.
Another medicine, which is often given to reflux patients, is a prokinetic drug. This means it is a medicine that causes the oesophagus and stomach to pump a little bit harder and therefore push acid downwards and reduce the likelihood that acid will come up above the valve and into the oesophagus. With these two treatments the majority of patients will quickly become symptom free.
Many patients also ask if we have cured the reflux problem by treating them with these medicines. The answer unfortunately is perhaps not, because as explained earlier the fundamental problem may be a weakness of the valve between the oesophagus and the stomach and this defect is not altered by medicines. What we have done is reduce acid production and increased the pumping of acidic stomach content downwards so that what reflux does take place is minimized and what reflux does take place is very low in acid content.
Are there ways of tightening the valve? There are. The most established method is surgery. There is a procedure called Nissen Fundoplication, which can be done either by an open surgical technique or a laparoscopic technique whereby a cuff of the stomach at the upper end is wound around the lower oesophagus and stitched so that it increases the pressure on the oesophageal sphincter. But this is major surgery under general anesthesia and for patients who have reflux that is not very severe which can be controlled in terms of symptoms and whose oesophagitis can be cured by means of medical treatment, we would not generally recommend that patients undergo surgical procedures because the risk-benefit ratio does not favor going for surgery.
Of course, if patients persist in having reflux it may be possible that they may need maintenance reflux treatments over a period of time or even indefinitely in order to feel comfortable. If patients are agreeable to this then that is not a problem. Some patients for their own preferences simply refuse to take long-term medications and may opt for surgery.