I acknowledge that this title is confusing and provocative. It's supposed to be. Read on to learn why the title is both true, and confusing.
Through doctors, the media, friends and family, the public is exposed to multiple definitions and explanations for the "heartburn" that affects up to 60 million Americans. A multitude of terms
have been used to describe this condition. At times these terms can be confusing, especially trying to find relief from the symptoms. What is this condition? Let's first do an inventory on all of the terms used to describe the condition of gastroesophageal reflux disease (GERD).
Terms for Gastroesophageal Reflux | Associated Terms |
Heartburn | Hiatal Hernia |
Reflux | LPR |
Acid Reflux | Barrett's Esophagus |
Acid Indigestion | Esophagitis |
GERD |
So exactly what is this condition? As you hear these terms used in TV or radio ads for medicines to treat "reflux", "heartburn", or "acid indigestion", and your doctor uses the exact same terms, sometimes all at the same time, its very hard to sort out exactly what the problem is, but more importantly what is the correct treatment.
Example Case (real life example)
Jane Doe has burning discomfort in her chest, especially after meals. She may even have the feeling of hot, burning fluid coming back up into her throat. Based on what she hears on TV or from friends with similar symptoms, she identifies this as heartburn caused by acid reflux, and Jane tries the over-the-counter medicine being advertised. Her burning discomfort (heartburn) goes away, but she still gets a mouthful of fluid and even some food coming back in to her throat if she bends over, especially after meals. She talks to her primary care physician (PCP) about this, and he tells her that she has acid reflux, and gives her a prescription for the same medicine advertised on TV, but in higher doses. After a month of this medicine nothing is different - the burning pain is gone, but she continues to regurgitate. Her PCP sends her to a gastroenterologist who tells her she probably has GERD and sets her up for an upper endoscopy. The upper endoscopy is normal, and the GI tells her that it is GERD and tries a different medicine and tells her to avoid acid producing foods. He also tells her she has "a small hiatal hernia and no Barrett's changes." This is all presented as good news. The conclusion is, GERD, nothing to worry about, avoid foods that cause symptoms, and keep taking the medicine prescribed.
Jane's response - REALLY! That's it. Jane is now in no-man's land. She is still having symptoms, and her scavenger hunt for an answer to what is really going on and how to best manage it has begun.
Every day in my office I see patients with a similar experience. Many have also see a surgeon who similarly throws these terms around loosely, and tells them that the only solution is surgery. Let me see if I can't make some sense of this. Much of what I have outlined so far is true, but there needs to be more care and thought in sorting out the problem and finding the best solution. So lets back up and answer some basic questions.
What is the Problem?
It's pretty simple. The problem is stomach contents flowing back up into the esophagus. Swallowed food and liquids once they get in to the stomach should stay there, and not come back up. That's it. All of the different terms used for this condition are describing symptoms or side effects of this back-up, also called regurgitation. The best term for this problem is reflux, or gastroesophageal reflux (GER).
What Causes It?
Now that we have the problem defined and the best terms to use established - reflux or GER, lets delve into what causes it.
There is a valve at the end of the esophagus whose job in life is to allow food to pass into the stomach, and then keep it there (See illustration below). That valve is called the lower esophageal sphincter (LES). It is supposed to stay closed, except when swallowing. During swallowing the LES opens to allow the swallowed food or liquid to pass into the stomach, and then close again. When the LES opens when there is no swallow, that is when reflux occurs.
Its just that simple. When the LES malfunctions and opens when it shouldn't, stomach content regurgitates into the esophagus - i.e., gastroesophageal reflux (GERD). Everything else is just differences in what is backing up into the esophagus. For example acid versus non-acid content. Now, how can we use this basic understanding to make sense of all the different ways reflux occurs and the different ways it is treated.
How Does the Kind of Reflux Impact Treatment
So far it seems pretty simple, right? What's all the confusion?
Before presenting a schematic with further explanation for the confusion, let me remind everyone that no one specialty has claimed the esophagus as their primary focus (see Post - Why Isn't There a Specialty for Esophageal Diseases?). With that, this problem is addressed by several different medical specialties with variable and often incomplete understanding of the problem and its solution(s). Hence, confused patients looking for help.
Below is my attempt to present in a schematic to clear up the confusion, and how what is backing up into the esophagus impacts symptoms, and the typical recommendations for treatment. The schematic has numbers with corresponding explanations below the schematic. Good luck. Hopefully this makes sense. Make comments and rate this at the bottom of the post if not.
The starting point is understanding that what is refluxing into the esophagus drives the symptoms and subsequent treatments.
If acid is what is backing up into the esophagus, then symptoms related to acid - heartburn, chest pain & acid regurgitation - are the main symptoms. Esophagus experts will characterize these as chemical symptoms to differentiate them from the symptoms from bland reflux (non-acid) which are typically mechanical symptoms (see Section 4 below). The primary treatment for acid reflux is to neutralize the acid with acid suppressing medicines like Pepcid or Nexium. These medicines stop the stomach from producing acid and in this way change the reflux from acid that burns, to bland reflux that doesn't cause burning pain or inflammation.
If acid suppressing medication eliminates all symptoms, this is a success. To be clear, reflux is likely still occurring, but is no longer causing symptoms. In the majority of cases the goal of treatment is to eliminate symptoms. Again, if medicine achieves this, that is success. While symptoms have been eliminated with medication, this may not be the best long-term solution. In another post I'll address how to decide about the best long-term solution. Subscribe to get alerted when new content is posted.
In some cases the content refluxing from the stomach is not acid, but rather bland (no significant chemical composition). To put this type of reflux in perspective, 90% of people with reflux will have acid reflux. Only 10% will have non-acid reflux. A caveat to this is someone who is currently being treated with acid suppressing medication which has stopped the acid symptoms, and now has only the non-acid reflux symptoms described in the schematic. Patients with non-acid reflux have more throat, breathing and voice symptoms. This constellation of symptoms is sometime called laryngopharyngeal reflux, or LPR. LPR is not a separate diagnosis, but rather, a form of reflux where the symptoms are mostly these throat and voice symptoms rather than the heartburn and chest pain of acid reflux.
As mentioned in no. 4 above, a patient who uses acid suppressing medication and eliminates the acid symptoms may transition to experiencing only the non-acid symptoms. Continuing to add more acid suppression medicine or acid reducing strategies will not be effective. Many patients at this point are referred to an ENT, who will rule out non-reflux causes of these symptoms (e.g., vocal cord polyps, post-nasal drip, etc.).
When symptoms are mechanical, and not chemical, medicine to alter the chemical nature of the reflux will fail. At this point the best treatment is to attack the underlying problem, the malfunctioning LES. There are several surgical procedures to accomplish this. Look for another Post of surgical options for treating reflux and fixing the cause of the problem, the malfunctioning LES valve.
Summary and Conclusion
The problem is reflux of stomach content in to the esophagus, and the cause is a malfunctioning LES.
The symptoms of this condition relate directly to whether the composition of what is refluxing in to the esophagus is acid or not. If acid, it is heartburn and chest pain and can appropriately be called acid reflux.
If not acid refluxing into the esophagus, or the acid has been treated with acid suppressing medication, then non-acid symptoms occur, and this best labeled reflux (not acid reflux). These symptoms are also sometimes called LPR.
Terminology and treatments should focus on this better understanding of the problem and its cause. Regrettably, pharmaceutical companies selling acid suppressing medications, and doctors who are not specialists in esophageal conditions will use the terms casually and inaccurately leading to confusion, delay in accurate diagnosis and treatment, and possibly needless suffering for long periods of time.
*This was a more complicated post to organize. Hopefully this was helpful. Please take some time to add comments and a rating to help me improve this post for others.
C. Daniel Smith, MD
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