Acid reflux: causes, symptoms, treatment

Have you ever experienced a burning feeling in your chest after eating three chili hotdogs with relish and extra mustard with an extra-large order of spicy curly fries? 

That’s acid reflux, and about 20% of people have this condition. You don’t have to be an adult to have acid reflux. Even babies can have it. Learn about what causes or triggers acid reflux and what treatments can help.

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Everything you eat or drink goes through your digestive tract: from your mouth down through your esophagus (food pipe) into your stomach. At the connection of the esophagus to the stomach, there is a muscle called the lower esophageal sphincter (LES) that keeps the food in the stomach once you’ve swallowed it. 

Your stomach produces a very powerful acid—hydrochloric acid—to break down food, so the rest of the digestive system can absorb all the nutrients, vitamins, minerals, and water.

Your stomach has a special lining that produces mucus to protect it against stomach acid. Your esophagus doesn’t have this lining, though. Sometimes the acidic stomach contents flow back up or regurgitate and can cause damage to the thinner lining of the esophagus. That’s why some call this gastrointestinal condition “indigestion” or “acid reflux.” Others may call it heartburn because the burning sensation of the stomach acid generally happens in the chest area. That's because the end of the esophagus is right near where the heart is in the chest. Healthcare professionals may call it gastroesophageal reflux disease, GERD, or GER (Antunes, 2021).

Types of acid reflux

There are three types of GERD (MacFarlane, 2015):

• Non-erosive reflux disease (NERD)—The reflux or regurgitation doesn’t damage the esophagus lining.

• Erosive esophagitis (EE)—The reflux damages (erodes) the esophagus lining. Some gastroenterologists may call this erosive reflux disease (ERD).

• Barrett’s esophagus (BE)—The lining of the esophagus changes and becomes precancerous from the constant exposure to the lower pH of stomach acid. This type of reflux is more common in males, older people, those of white ethnicity, and with abdominal obesity (Khieu, 2020). 

Typically, when you eat or drink anything, the lower esophageal sphincter opens up a little to allow the food to pass through into the stomach. Once it has passed through, the sphincter immediately tightens up to prevent the food or liquid from going back up the esophagus. With acid reflux, the sphincter either doesn't close all the way, or it closes and then reopens a bit. When the sphincter is open, stomach or gastric contents can go upward (regurgitation). The acid hits the esophagus and damages its inner lining (Antunes, 2021).

Several factors can cause GERD. These factors weaken the lower esophageal sphincter's strength or cause it to loosen. Some of these are physical or medical conditions, and some are lifestyle-related.

Medical conditions

• Pregnancy—Higher levels of progesterone in pregnancy relax smooth muscles, including the lower esophageal sphincter. The expanding uterus can also cause pressure on the stomach contents, encouraging them to wash back up the esophagus (Vazquez, 2015).

• Hiatal hernia—Your diaphragm, the big, flat muscle just beneath your chest, functions as a "muscular guard" to keep your esophageal sphincter in place. A hiatal hernia happens when there's an opening in the diaphragm and the upper part of the stomach. The stomach sticks out through that space. Now the upper part of the stomach is higher than the esophagus, so the acid easily flows back up through the esophagus. Hiatal hernias can happen suddenly from physical strain on the diaphragm, like from vomiting or constant coughing. It can also occur from increased pressure from the abdomen, usually from pregnancy, obesity, chronic obstructive pulmonary disease (COPD), or chronic constipation. It is prevalent in people over 50 (Smith, 2020).

• Diabetes—Scientists theorize that diabetes-related neuropathy or nerve damage can make people with diabetes more prone to Hiatal hernias (Ha, 2016).

• Obesity—Obesity can cause increased pressure on the diaphragm (Fass, 2016). 

Lifestyle factors 

Certain lifestyle factors can increase your likelihood of developing acid reflux (Kiefer, 2015):

• Certain foods—Caffeine, citrus fruits, tomatoes, spicy foods, fried food, fatty food, chocolate, garlic, and peppermint flavor 

• Eating habits—Eating before bedtime (less than three hours before going to sleep), eating too fast, or eating too much

• Alcohol

• Smoking

• Bad posture—Constantly slouching or sitting for too long

• Wearing tight clothing

• Medications—Nonsteroidal anti-inflammatory drugs (NSAIDs), certain antibiotics, antihistamines, nitrates, calcium channel blockers, statins, steroids, and vitamin C. If you take any medications and experience acid reflux, you may wish to discuss it with your healthcare provider (MacFarlane, 2018).

So, what does acid reflux feel like?

The most common symptom of GERD is constant, persistent heartburn, a painful, burning sensation in the chest behind the breastbone. It starts at the top of the stomach, spreads upward towards the neck and throat, and usually worsens after eating. The pain can last for a while, but heartburn or indigestion pain doesn't increase with physical activity. In fact, laying down in bed or bending forward can increase the pain (Antunes, 2021).

Some people with GERD may have these symptoms instead, or in addition to heartburn or indigestion (Antunes, 2020):

• Dental erosion from acid washing up toward the teeth

• Bitter or sour taste in the mouth, constantly or only when lying down or bending over

• Hoarseness

• Difficulty swallowing

• Sore throat

• Nausea

• Constant dry cough

• Chest pain

• Wheezing and asthma

• Pain in the upper abdomen

Babies and children can also have GERD. Their symptoms differ slightly. They’re more likely to cough, have repeated vomiting, and develop respiratory issues.

Everyone has short 10 to 45-second openings of the lower esophageal sphincter to allow the stomach to "vent gases" (commonly called a burp). These short openings are called transient lower esophageal sphincter relaxations (TLESRs). People with GERD symptoms like heartburn do not have more TESLRs than people without GERD symptoms. Still, they may have more heartburn and other GERD symptoms during a TLESR opening (Herregods, 2015).

Complications of GERD

Most people with GERD have mild to moderate acid reflux, but some people can develop further complications, such as (Clarrett, 2018):

• Esophageal ulcers/esophagitis—Includes inflammation, ulceration, and irritation of the inner lining of the esophagus. Sometimes, some of the ulcers bleed.

• Strictures—The esophagus narrows in areas where scars have formed from chronic acid reflux and regurgitation. Strictures can cause difficulty swallowing.

• Asthma—Stomach acid can enter the throat and go into the respiratory system, causing inflammation and wheezing.

• Barrett’s esophagus—Precancerous changes to the esophagus

• Esophageal cancer—A rare cancer that affects the esophagus

If you suffer from acid reflux and heartburn, you may want immediate relief from the symptoms. Acid reflux can decrease your quality and enjoyment of life, interfere with your sleep, and lower your productivity (Antunes, 2020).

Antacids

Most people don’t go to their healthcare provider the first time they have heartburn. They may go to a drugstore or mass retailer and buy an over-the-counter (OTC) medicine called an antacid to treat the symptoms. Antacids work by neutralizing the hydrochloric acid from the stomach. They often have sodium bicarbonate, calcium, aluminum, or magnesium base. Some may add alginate, which creates a gel to coat the bottom part of the esophagus, blocking the acid from traveling upward or directly irritating the esophagus (MacFarlane, 2015). 

Some popular antacid brands are: 

• Alka-Seltzer

• Tums

• Rolaids

• Mylanta

H2 blockers

Other medications are available as over-the-counter medications or by prescription from a healthcare professional to treat acid reflux.

One is histamine H2 receptor antagonists. They can also be called H2 blockers. These drugs lower the amount of acid produced by the stomach (MacFarlane, 2015).

Some popular H2 blockers include:

• Pepcid (famotidine)

• Tagamet (cimetidine)

• Zantac (ranitidine)

• Axid (nizatidine)

Proton-pump inhibitors

Another class of medication is proton-pump inhibitors or PPIs, which are the strongest of all acid reflux medications. They work by blocking acid production from the special "pumping" stomach cells into the stomach. These work best when taken before a meal and with a consistent daily schedule (MacFarlane, 2015).

Some available PPIs are:

• Prevacid (lansoprazole)

• Prilosec (omeprazole)

• Nexium (esomeprazole)

Lifestyle modifications

Your gastroenterologist may prescribe any of the medications listed and may also encourage you to alter your lifestyle to reduce acid reflux. Some lifestyle modifications that can help include (Antunes, 2021):

• Stop drinking alcohol.

• Stop smoking.

• Stop eating large meals at least three hours before bedtime.

• Limit foods that trigger your acid reflux. For some, this may include fatty foods, while for others, spicy foods may be a trigger.

• Eat smaller meals.

When to seek medical attention for GERD

Suppose your GERD symptoms don't get better with OTC medications, or you find that you are frequently using OTC medications multiple times a week. In that case, you may want to visit your primary care provider or gastroenterologist. Tests for acid reflux diagnosis include (Koch, 2016):

• X-rays—You may need x-rays of your esophagus, stomach, and part of your small intestine. This is called an upper GI series. You’ll take a barium swallow (a chalk-like drink) or barium pill that helps the radiologist visualize the upper part of your digestive system.

• Endoscopy—This is where a gastroenterologist puts a thin, flexible tube with a camera and a light down your esophagus. The endoscopy is done under sedation, meaning that you'll be asleep or unaware during the procedure. This test looks for inflammation, ulcers, and strictures and can include a biopsy to diagnose Barrett's esophagus or esophageal cancer.

• Esophageal manometry—This test checks how well your esophageal muscles work when you swallow. It measures their coordination, force, and rhythm.

• Ambulatory acid pH probe monitor—For this test, you will wear a small computer over your shoulder in a strap or around your waist (fanny pack). Your healthcare provider will place a thin, flexible, wearable monitor (sometimes called a catheter) in your nose, down to your esophagus. You will wear this probe for 24 hours. Alternatively, your gastroenterologist may put a clip in your esophagus while doing your endoscopy. The clip will pass through your digestive system after two days.

Your gastroenterologist and radiologist will let you know your diagnosis after your test. Some GERD cases are severe and may require surgery. 

If you've been diagnosed with GERD and notice any of the following symptoms, please go to the nearest emergency room. Some of these may be symptoms of a heart attack or other medical emergency (Clarrett, 2018):

• Difficulty swallowing

• Shortness of breath

• Intense chest pain radiating to your back, arms, or neck

• Vomiting blood

• Vomiting with intense chest pain

• Very dark (almost black) stools

Most people with mild acid reflux can decrease their symptoms with dietary and lifestyle changes. Those with mild to moderate acid reflux can often get relief with OTC or prescription medications. If you do not get relief from lifestyle adaptations or acid reflux medications, be sure to consult your healthcare provider.

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Current version

May 03, 2021

Written by

Tobi Ash, MBA, RN, BSN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.