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What are the unresolved issues in GERD (acid reflux)?

Mechanism of heartburn and damage

One unresolved issue in GERD is the inconsistent relationships among acid reflux, heartburn, and damage to the lining of the esophagus (esophagitis and the complications).

  1. Why do only a few of the many episodes of acid reflux that occur in a patient with GERD cause heartburn?
  2. Why do some patients with mildly increased acid reflux develop heartburn, while other patients with the same amount of acid reflux do not?
  3. Why does heartburn usually occur in an esophagus that has no visible damage?
  4. Why is it that some patients with more damage to the esophagus have less heartburn than patients with no damage?
  5. Is heartburn not related to inflammation but rather to absorption of acid across the lining of the esophagus through widened spaces between the lining cells?

Clearly, we have much to learn about the relationship between acid reflux and esophageal damage, and about the processes (mechanisms) responsible for heartburn. This issue is of more than passing interest. Knowledge of the mechanisms that produce heartburn and esophageal damage raises the possibility of new treatments that would target processes other than acid reflux.

One of the more interesting theories that has been proposed to answer some of these questions involves the reason for pain when acid refluxes. It often is assumed that the pain is caused by irritating acid contacting an inflamed esophageal lining. But the esophageal lining usually is not inflamed. It is possible therefore, that the acid is stimulating the pain nerves within the esophageal wall just beneath the lining. Although this may be the case, a second explanation is supported by the work of one group of scientists. These scientists find that heartburn provoked by acid in the esophagus is associated with contraction of the muscle in the lower esophagus. Perhaps it is the contraction of the muscle that somehow leads to the pain. It also is possible, however, that the contraction is an epiphenomenon, that is, refluxed acid stimulates pain nerves and causes the muscle to contract, but it is not the contraction that causes the pain. More studies will be necessary before the exact mechanism(s) that causes heartburn is clear.

Importance of non-acidic reflux

There are potentially injurious agents that can be refluxed other than acid, for example, bile. Until recently it has been impossible or difficult to accurately identify non-acid reflux and, therefore, to study whether or not non-acid reflux is injurious or can cause symptoms.

A new technology allows the accurate determination of non-acid reflux. This technology uses the measurement of impedance changes within the esophagus to identify reflux of liquid, be it acid or non-acid. By combining measurement of impedance and pH it is possible to identify reflux and to tell if the reflux is acid or non-acid. It is too early to know how important non-acid reflux is in causing esophageal damage, symptoms, or complications, but there is little doubt that this new technology will be able to resolve the issues surrounding non-acid reflux.

Return to GERD (Acid Reflux, Heartburn)

See what others are saying

Comment from: brandon7, 35-44 Male (Patient) Published: January 14

I was having heartburn, belching and pain on my right side and chest after eating, for over a month. My doctor did an ultrasound thinking it was gallstones. Results came back negative. He put me on once a day Prilosec but it wasn't helping. I tried Prevacid and it made me feel bloated and gassy but I was still in pain. My doctor referred me to a gastroenterologist and he immediately put me on twice a day pantoprazole and sent me to have an endoscopy two weeks later. Twice a day pantoprazole helped quite a bit but I still felt pain. After the endoscopy, he said I had possible Barrett's esophagus but the pathology report came back negative for Barrett's a week later (thank goodness). I was diagnosed with a hiatal hernia and mild gastritis. The 2 times a day pantoprazole was making me feel awful, bloated and gassy and constipated but was helping my pain. I switched to Nexium and immediately felt much better (reduced pain and no gas or bloating). I also purchased a sleeping wedge and it greatly helped my symptoms. I am now down to one Nexium per day and 99 percent pain free. I would say to try several proton pump inhibitors to see what works best. I tried Prilosec, Prevacid, pantoprazole and finally Nexium. Also, consider a sleeping wedge, it also seemed to greatly help. I no longer wake at night with pain and when I get up in the morning I don't feel anything. I also now watch my diet better (no coffee or chocolate or spicy foods) and don't seem to have problems. I was worried I might need surgery but my gastroenterologist kept telling me not to do it and he was confident he could help me get back to feeling good again. It has taken a couple months but I'm not feeling like I'm back to my old self.

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Comment from: Hopeful, 45-54 Female (Patient) Published: September 22

I have just been diagnosed with GERD after I started having hoarseness in my voice. Doctor has prescribed medication for me which I am currently taking. However the hoarseness hasn't gone away completely. I am taking omeprazole, clarithromycin and ranitidine tablets for now.

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Comment from: here to help, 35-44 Female (Patient) Published: May 30

I recently had an upper endoscopy done. I was having things get stuck in throat; hard to swallow my own spit (sorry), even water, hiccups, and my throat felt swollen. I felt full all the time and nauseated. I was found to have candida (yeast or thrush). The doctor took biopsy. Plus, I had so much fat sitting in my stomach that wasn"t digested, he suctioned it out. I did have a scope last year. I don"t think it was called an endoscopy. I have GERD, hernia, and gastroparesis which is slow emptying of stomach by 50%. You needed to eat a radioactive egg to see how fast you digest food; it"s also good to see how you digest medications. This can be a big problem if food is sitting in your stomach longer than it should. It could cause problems from your throat to your colon. I know because I now need a colon resection and have outer rectal prolapse at age 42. I need part of stomach removed and looking at esophagus surgery. I do hope this message helps at least one person out there. I found a great internal medicine doctor, bless his heart.

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