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Medical Edge Newspaper Column from Mayo Clinic

QUENCHING THE FIRE DOWN BELOW: ACID REFLUX TREATMENTS

DEAR MAYO CLINIC: My 82-year-old mother wakes up every morning choking and spitting up phlegm. Because her mouth is sore and extremely dry all the time, everything she eats burns and hurts. She has been diagnosed with acid reflux, but none of the medications have helped and her symptoms continue to make her miserable. Are there any other treatment options for acid reflux? — Orange Park, Fla.

ANSWER: Given your mother’s symptoms and her unresponsiveness to medication, it’s possible that her problem is not acid reflux.

First, the majority of patients with acid reflux report heartburn, a burning sensation in the chest that actually has nothing to do with the heart. It is instead caused by stomach acid that flows back into the esophagus (food pipe), thus irritating its lining. If your mother does not experience chronic heartburn — you didn’t mention it — yet she has acid reflux, her case would be atypical.

Second, the medications we now have for treating acid reflux are highly effective — so effective that when a person fails to respond to them, we need to question the acid reflux diagnosis. I’m referring in particular to proton pump inhibitors — esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) or rabeprazole (Aciphex) — which by blocking acid production bring relief to about 90 percent of patients.

But let us suppose that other possibilities, such as sinus diseases with post-nasal drip, are ruled out. We have three kinds of options for dealing with acid reflux. The first is to increase the dose of the medication. Some 20 to 30 percent of previously unresponsive patients, particularly those with atypical symptoms, show improvement with higher doses.

Another option is surgery to strengthen the lower esophageal sphincter — a muscle that normally serves as a barrier to prevent stomach contents from entering the esophagus. The procedure of choice is Nissen fundoplication, by which the fundus — the upper, saclike area of largely redundant stomach tissue — is wrapped around the sphincter to strengthen its open-close mechanism.

The third option is endoscopic treatment, a nonsurgical procedure in which a long, flexible tube is inserted into the mouth and passed into the esophagus. One of four variations to this approach — which essentially amount to stitching, stapling, burning (via radiofrequency energy) or injecting — may be used to reinforce the barrier between stomach and esophagus. These methods are less invasive than surgery and more convenient than long-term medication, but they are relatively new and still being evaluated.

Self-care or lifestyle changes — for example, controlling one’s weight, eating smaller meals, wearing loose-fitting clothes, avoiding heartburn-triggering foods, avoiding stooping or bending, not lying down after a meal, raising the head of one’s bed, not smoking and reducing alcohol consumption — can also be useful adjuncts to standard treatment.

If the acid reflux problem is mild, over-the-counter medications such as antacids sometimes provide sufficient relief, at least for a while. This is usually adequate for the many millions of people who experience heartburn from time to time but who do not have gastroesophageal reflux disease, the formal name for acid reflux. GERD typically causes frequent or persistent heartburn. For those who have GERD, numerous treatments are available, and they can be combined.

It’s worth noting that acid reflux can be caused or exacerbated by other medical conditions — obesity, hiatal hernia (part of the stomach protruding into the lower chest), asthma or diabetes. Consult with a specialist who can help you and your mother sort out exactly what is causing her troublesome symptoms.

— Virender Kumar Sharma, M.D., Gastroenterology, Mayo Clinic, Scottsdale, Ariz.

Additional Resources:
Acid Reflux
Appointment Information
More Information on Acid Reflux

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Medical Edge from Mayo Clinic is an educational resource and doesn’t replace regular medical care. To e-mail a question, go to www.mayoclinic.org, or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For health information, visit www.mayoclinic.com.