AN OVERVIEW OF REFLUX OESOPHAGITIS - a patient's guide
Dr Cliff Tasman-Jones - Gastroenterologist
Reflux oesophagitis is an inflammation of the oesophagus (gullet)
resulting from a failure of the valve (lower oesophageal sphincter)
between the oesophagus and the stomach. In health, the valve prevents
the back flow of gastric juices. The symptoms of reflux oesophagitis
are common, often considered trivial and frequently managed by simple
home remedies or over-the-counter antacids. Untreated it can progress
to serious disease in some people.
This fact sheet provides information on the causes, symptoms,
treatment, and longer-term complications of reflux oesophagitis.
What is gastro-oesophogeal reflux?
Gastro-oesophageal reflux is the back flow of stomach contents
into the oesophagus.
Normally the lower oesophageal sphincter opens to allow food and
fluid to pass into the stomach and then closing to prevent food and
acidic gastric juices flowing back into the oesophagus. Reflux occurs
when the lower oesophageal sphincter is either weak or relaxes
inappropriately allowing corrosive gastric contents to flow backcausing inflammation of the oesophagus.
Does reflux occur in healthy people?
A small tube which measures acidity when placed in the oesophagus
shows that everyone has short periods of reflux. These are usually of
short duration lasting a minute or two, with a total time of less
than half an hour in a 24 hour period.
Inflammation occurs when the exposure to stomach contents is
prolonged and the stomach juices refluxed have a high acid and pepsin
Why does the oesophagus become inflammed and not the
An important function of the stomach is to produce and store very
strong acids. Acid have roles in breaking down food for digestion,
and killing unwanted infectious organisms. In order to store the
juices which would digest other organs and tissues, the stomach
evolved a very effective barrier layer which protects it almost as
well as if it were ceramic bowl. The uniqueness that in spite of this
remarkable protective layer it is still able to allow passage of
those foods and fluids required by the body.
The barrier layer over the oesophagus is much weaker and not
designed to resist the aggressive stomach juices. The barrier is
sufficient to provide temporary protection but long exposure results
in inflammation with swelling, redness and sometimes pain - the
hallmarks of oesophagitis.
What causes reflux oesophagitis?
The causes may be divided into two groups - those with a normal
lower oesophageal sphincter and those with poorly functioning
Increases in the pressure in the abdomen can overcome the strength
of a normal valve. Such pressure increases may be associated with
pregnancy, obesity, bending when the stomach is full, large amounts
of free fluid in the abdomen (ascites), physical exertion including
coughing, vomiting, or straining, and sometimes very tight
Impairment of sphincter pressure function can be caused by some
foods including coffee, chocolate, peppermint, fried and fatty foods,
and alcohol; some pharmaceutical medications. Cigarette smoking
relaxes the valve. The importance of hiatus hernia is
What is the role of hiatus hernia?
When the upper part of the stomach moves up into the chest through
the diaphragm, the person is said to have a hiatus hernia. In its
normal position the gastro-oesophageal valve has additional support
from the muscles of the diaphragm. When the stomach is not in its
preferred position with loss of diaphragmatic support there is
lowering of the pressure available to prevent reflux.
Many healthy people have a small hiatus hernia. Hiatus hernia is
more common as we age and it can be shown by x-ray examination in
most people over 50. Many with a hiatus hernia have no symptoms and
are unlikely to ever have symptoms. It is argued that hiatus hernia
is a normal aging change and not a disease.
However, hiatus hernia is associated with more reflux oesophagitis
than would be expected suggesting that the loss of the effect of the
muscles in the diaphragm and the change of the angle in which the
oesophagus enters the stomach, sufficiently weakens the effect of the
sphincter mechanism to play a significant part in many with
oesophageal reflux disease.
What are the symptoms of reflux oesophagitis?
Heartburn is the characteristic symptom. Described as a burning
pain behind the breastbone, it most commonly occurs after eating. It
can, however, occur on bending, lying down, straining, after coffee,
and even with emotional stress. It may last up to two hours and is
often relieved by taking an antacid.
While heartburn means reflux oesophagitis, it can occur with spasm
of the oesophageal muscle without inflammation. It can be confused
with heart pain. There are differences between heart pain and
oesophageal pain. Heart pain usually is associated with exercise and
the pain radiates into the left arm.
Other symptoms are a feeling of food coming back into the mouth,
leaving an acid or bitter taste. There may be a feeling of delay in
the passage of food with discomfort associated with swallowing.
Waking at night with coughing, a feeling of tightness in the chest
and a wheeze may occur due to refluxed stomach contents being
How is reflux oesophagitis diagnosed?
Endoscopy is the gold standard for diagnosis. The appearance can
be photographed and a biopsy obtained.
Because the symptoms are characteristic, and providing heart
disease can be reasonably excluded, some argue that for milder
symptoms, treatment on the history alone is safe and cost effective.
This advice can be endorsed providing if treatment is unsatisfactory,
the endoscopy is then done.
What is the treatment for reflux oesophagitis?
Treatment should consider lifestyle factors, consideration of drug
treatment, and surgery.
What lifestyle changes?
Reduce or remove foods and beverages that are known to reduce the
strength of the valvular mechanism - chocolate, coffee, peppermint,
fried and fatty foods, and alcohol.
Decrease foods that irritate inflammed tissue - citrus fruits and
juices, pepper, and some tomato products.
Lose weight if overweight and decrease the size of mealtime
Consider elevation of the head of the bed to aid better drainage
from the stomach.
What drug options are available?
Antacids taken regularly can neutralise acid in the oesophagus and
stomach. For very mild symptoms this is the simplest satisfactory
medication. Usually the relief is temporary and too much antacid can
have its own side effects.
More specific is to reduce the acid production of the stomach.
Histamine 2 receptors antagonists are capable of reducing the gastric
acid output by 70 or 90 percent. Four members of this group are
available - Cimetidine, Ranitidine, Famotidine, and Nizatidine. These
can be used intermittently or for long maintenance programmes.
Almost total suppression of acid can be obtained by using a proton
pump inhibitor. These are used almost exclusively for the very severe
diseases. There are three proton pump inhibitors in New Zealand -
Omeprazole, pantopraxole, and lansoprazole.
Other treatments which may be considered are prokinetic agents
which aid clearance of fluid from the oesophagus and improve the
strength of the lower oesophageal sphincter. There are three of these
agents available - metoclopramide, domperidone, and cisapride.
What about surgery?
Surgery for reflux oesophagitis has been controversial. Surgeons
have always had a place in the management of disease unresponsive to
drug treatment and disease with complications. The recent advances in
laproscopic surgery techniques - a less invasive procedure than open
surgery - have renewed interest in surgery for the less severe forms
of the disease. A procedure known as fundoplication, modifies the
angle between the oesophagus and the stomach, making it more acute
thus creating a valve action which closes when pressure in the
stomach is increased.
A feeling of fullness (early satiety), abdominal distention, and
food sticking in the gullet (dysphagia) are early symptoms with
surgery. These settle quickly in most, but a small number may
continue with distension, some difficulty in swallowing, and
What are the complications of reflux oesophagitis?
Sometimes serious complications develop. Bleeding may occur.
Ulcers can develop leading to scarring and narrowing (stricture) of
the oesophagus. Cancer is a remote possibility which cannot be
Reflux oesophagitis is a disorder with a wide spectrum of symptom
intensity which spoils quality of life and which, for a few, can
cause severe life threatening illness. Because of the potential for
serious complications the symptoms should never be ignored as
trivial. The treatment options usually advance along the lifestyle,
pharmaceutical drugs and finally to the surgical options.
Laparoscopic fundoplication surgery is being considered earlier than
in the recent past.
Bowel And Abdominal Problems
Dr Cliff Tasman-Jones
Copyright © 2009 The Online Services Group (N.Z)