Acid Reflux / GERD – The Ultimate Guide

Believe it or not 15-30% of Americans suffer from some form of acid reflux. For some it will be minor only affecting them on rare occasions, whereas for others it could be much more troublesome. Acid reflux sometimes called hyperacidity is due to acid refluxing up out of the stomach and into the esophagus and even the throat where it shouldn’t be.

If you didn’t already know GERD stands for gastroesophageal reflux disease which is basically the bad form of acid reflux. Typically speaking someone who has more chronic acid reflux may be deemed to have GERD. 

One of the more common symptoms that affects people with acid reflux is things like heartburn and chest pain but you can also be affected with things like hoarse voice or sore throat which is usually more related to another form of acid reflux called silent reflux which in fact should be treated differently than regular acid reflux and GERD. 

I will be covering everything about acid reflux and GERD below – including what causes acid reflux, the symptoms you may have, how to diagnose it and how it can be treated both naturally, medically and even surgically in more extreme cases.

Acid Reflux Causes

#1 Diet

Probably one of the most common causes of acid reflux is diet which is often what leads to too much stomach acid. What you are eating and drinking is a prime cause of what happens with your digestive system unsurprisingly. Certain foods and drinks will undoubtedly cause digestion problems which can in turn induce acid reflux. Some of the most common foods and drinks that cause this are –

(red) – should be avoided by all reflux sufferers

(orange) – should be avoided by most reflux sufferers

(yellow) – can be tolerated by certain people with acid reflux effects

Soft Drinks

Soft drinks are probably some of the worst things you can take if you have acid reflux. They are highly acidic and also the carbonation adds pressure to the stomach. This adds pressure to the stomach that can induce the lower esophageal sphincter(LES) to open and thus give you acid reflux. If you didn’t know the LES is the valve above the stomach which is designed to keep the acid and food contents inside the stomach.

Alcohol

There have been studies done to show that drinking most alcohol beverages triggers and increases acid production in the stomach which could worsen or induce acid reflux problems. Particularly if you drink a lot of it.

Processed Foods

The more processed foods you eat, the more likely you are to have acid reflux problems. This is because processed foods tend to take longer to digest and break down than something that is completely natural. While processed foods aren’t necessarily the worst trigger for acid reflux they can definitely contribute to it.

Spicy Foods

As I am sure you may have guessed that spicy food is not good for acid reflux. This is because of it’s higher acidity. Also when the food is passing over the esophagus it can further irritate any areas which may have been recently irritated due to acid reflux.

Tomatoes, Onions, Garlic

Tomatoes and onions are quite acidic and should be avoided, particularly if you have more severe acid reflux. Garlic is also a trigger for some people and should be avoided by them. If you want onions, sweet onions(purple onions) should be fine because they are less acidic than normal onions. If you have mild acid reflux you may not need to avoid these.

Fatty Foods/Deep Fried Foods

Foods that are higher in fat take longer to digest. Because the digestion takes longer this means more exposure to acid reflux. Also fats are harder to break down so this means the stomach has to exert itself more, which means it moves around more which also increases the chance of more acid reflux.

Chocolate

Sometimes people get confused about chocolate and acid reflux and rightly so. As I am sure you aware most chocolate is made primarily from milk and sugar both of which aren’t too acidic and should be fine for the stomach. The issue with chocolate is because of something that it includes. This something is called methylxanthine. 

The issues with methylxanthine is that it causes tissue muscles in the body to relax. The problem with this is the LES(valve above the stomach) is one of these muscles in the body. If the LES relaxes more than it should it causes the valve to remain open which will cause acid reflux. That is the main reason you want to avoid chocolate.

Citrus Fruits

If you suffer from mild acid reflux or serious acid reflux citrus fruits like oranges, grapefruit should be avoided. If you have a more serious acid reflux problem like GERD it may be a good decision to avoid other acidic fruits like berries, kiwis, apples etc. To give you an idea of the few least acidic fruits try melons, bananas, pears etc.

Coffee

Just like I mentioned with chocolate, coffee contains methylxanthine which can loosen the LES which will make acid reflux worse. So avoiding coffee is particularly important especially if you suffer from more severe acid reflux.

#2 Being Overweight

One of the possible causes of acid reflux is being overweight. Let me explain how this works. Basically when someone is overweight, particularly in the stomach area this can cause or make acid reflux worse. 

This is because of the added weight around the stomach area puts pressure on the LES (the valve above the stomach). Because of this added pressure on the LES it makes it more likely to open which allows for the acid to come up and give you the acid reflux symptoms. 

#3 Lifestyle Choices

When I say lifestyle choices this is because of a selection of different things. Below I will cover a few of the most important ones you should know if you have acid reflux.

Overeating – 

Something that isn’t often talked about when it comes to acid reflux is overeating. What I mean by this is basically eating too much in one sitting. If you didn’t know the average stomach is about the size of your fist. That means if you eat more food than the size of your fist then this puts more pressure on the stomach and importantly the LES which is more likely to open. 

This is particularly true when the stomach is full because it has to move to help digest the food and this can result in it spilling up into the esophagus which is more likely when your stomach is overloaded.

Overdrinking – 

The same thing applies to over drinking as it would to overeating. Drinking too much puts more pressure on the stomach, this is not just alcohol but any drink, carbonated drinks are particularly bad because the gas further increases the pressure. 

In fact in an ideal world I would recommend limiting liquid intake when eating because this puts more pressure on the stomach and could heighten the chance of reflux when you drink more when eating.

Eating Before Sleeping – 

Eating before sleeping or laying down is something you should want to avoid when you have acid reflux. 

Ideally you shouldn’t sleep/lay down until at least 3 hours after eating. The reason for this is because when you are laying down you don’t have the advantage of gravity helping keep your food and acid in your stomach. 

If you wait a few hours before you lay down this greatly reduces the chance of nighttime reflux because the stomach shouldn’t be digesting when it’s mostly or completely empty.

#4 Stress & Anxiety

Something that needs to be talked about more when discussing acid reflux is stress and anxiety. It is probably one of the less commonly talked about causes of acid reflux but it definitely affects a lot of people. 

For me I am certain that stress started my own acid reflux problems and when I improved and helped the stress and anxiety my symptoms definitely improved. There have been plenty of studies confirming this notion for example this study interviewed over 12,000 people with GERD where over half of the participants stated that stress was the biggest factor that worsened symptoms. For more advice on dealing with stress and anxiety, check out this article.

#5 Smoking

You should avoid smoking if you have acid reflux. It can weaken the LES and also can prevent and limit healing of both the esophagus and the throat. 

Smoking is also carcinogenic – it would be an excellent decision to stop if you suffer from acid reflux.  

#6 Certain Medications

Quite a lot of medications can worsen and even cause acid reflux. Below I will name a few of the more prominent ones that cause issues.

Anti-inflammatories, Antibiotics – These are known to be bad on the stomach and digestive system. They can cause problems for people particularly if taken long term.

Vitamin C – Most vitamin c tablets are made up from ascorbic acid which is highly acidic and can worsen and even bring on acid reflux particularly in larger doses and lead to excessive stomach acid and acidity.

A few others include aspirin, blood pressure medications or certain muscle relaxers

#7 Pregnancy

Similar to the principle of when someone is overweight being pregnant creates more pressure on the LES, the same thing can be applied to when a woman is pregnant because the baby can put more pressure on the LES which then increases the chance of reflux. 

It can also affect around the stomach and general digestive system which too can alter things leading to reflux. Also there is the possibility of hormonal changing things like the muscles in the esophagus and the LES to relax more frequently.

Acid Reflux Symptoms

Heartburn – probably the most common symptom of acid reflux is heartburn. When the acid refluxes up and out of your stomach this can irritate just above the stomach or even further up the esophagus – this is what causes the feeling of heartburn.

Regurgitation – when acid refluxes up from the stomach so also can food. This food can also possibly reflux the whole way up and into the mouth.

Bloating – bloating is a sign that something isn’t right or going well with your digestive system and sometimes there is a correlation between it and acid reflux.

Burping – just like bloating if you are burping more than normal this shows something isn’t quite right with your digestion. This often means more possibility of reflux. If you are burping more frequently you will have more gas which means more pressure and gas being released from the stomach which is a prime opportunity for the acid to reflux up into your esophagus and throat.

Nausea – if you feel sick, clearly something isn’t right with your digestion so there is definitely a correlation.

Weight Loss – sometimes if you are losing more weight than is normal this could be a sign of acid reflux, whether that’s poor digestion/absorption etc. this could cause you to lose weight.

Throat issues including (sore throat, cough, dry throat, feeling of lump in the throat, hoarseness) – if you are experiencing any of this symptoms to do with your throat you could likely be suffering from a kind of acid reflux called Laryngopharyngeal reflux(LPR) or sometimes called silent reflux. Usually someone who suffers from LPR only has symptoms affecting their throat etc. This is why it’s sometimes called silent reflux because people with LPR typically don’t have the usual acid reflux symptoms like heartburn although it is possible to have both GERD and LPR. You can read more about LPR in my complete guide to LPR.

Ear Pain – in quite rare situations acid reflux can cause ear pain believe it or not. This is because of a tube that connects the throat and the ears called the eustachian tube. A digestive enzyme called pepsin refluxes up and into the throat along with acid and then can enter this tube and then into the ear – this is how problems can arise. For more information check out this article – acid reflux and ear pain.

Bad Breath – the acid refluxing up and into your esophagus and even throat can lead to bad breath. So it’s quite a common cause.

Acid Reflux Treatment

Diet

Probably the best way for everyone to improve or completely stop acid reflux for most people is by altering your diet. For some people they will simply need to avoid a few foods/drinks whereas for others they may need to follow a much more strict diet – for example people with silent reflux should ideally avoid foods of an acidity rating of 5 pH or less. 

The point of the argument is that what you are eating should be the first thing you should change before considering any medication. The first thing you should be considering is limiting some of the most common trigger foods and drinks of acid reflux.

As I already mentioned in the causes of acid reflux above in this article are these acidic foods and drinks. To re-mention the foods and drinks you should be avoiding if you have acid reflux are –

• Soft drinks
• Alcohol
• Processed foods
• Spicy foods
• Tomatoes, onions, garlic
• Fatty foods/ Deep fried foods
• Chocolate
• Citrus fruits
• Coffee

Lifestyle Changes

Alongside diet lifestyle choices are probably some of the most important changes that should be considered. Sometimes these aren’t made evident enough and could even be related to the direct cause for someone acid reflux in the first place. As I already talked about in the causes for acid reflux these 3 things must be looked at –

• Overeating – keep portions sizes smaller, ideally about the size of your fist. This way the stomach is never overloaded and this greatly reduces the chance of reflux. It’s best to eat small meals more often then fewer larger meals. For people with minor acid reflux this shouldn’t be a major concern whereas for people with GERD/LPR it should be.
• Overdrinking – the same thing applies to overdrinking. Don’t drink too much in one sitting because this will add more pressure to the stomach. It’s also best to not drink too much when eating because it to adds to this increased load and pressure.
• Eating Before Sleeping – simply don’t eat soon before bed. Ideally you should eat at least 3 hours before sleeping or laying down. If you ate and then lay down the stomach has more pressure on it and particularly the LES which increases reflux probability mainly because you don’t have gravity helping.

Lowering Stress / Anxiety

As I mentioned in the causes for acid reflux, stress and anxiety are some of the sometimes overlooked areas of acid reflux causes. Needless to say it’s something that should be seriously considered before as it could bring on your acid reflux in the first place. Some things to consider to help –

Meditation – Of course this may be a obvious thing that can be proposed to help with stress and anxiety although so I really recommend you try it. Nowadays it’s as simple as installing an app on your phone and following some breathing exercises. Trust me that it can really help and it definitely helps taking your mind off things.

Mentality – Obviously mentality is one of the main things that could be inducing your stress or reflux problems. There are many books on dealing with things like this. I would personally recommend you check out this one – “How to Stop Worrying and Start Living”, it really helped changed my mentality and definitely helped with improving my mindset and attitude which I am confident helped my acid reflux.

Tea – One more small recommendation is having some tea. Not just any tea but chamomile tea. Chamomile tea helps relax and calm the body so it’s worth trying. For more information on chamomile tea check our article – Is Chamomile Tea Good For Acid Reflux?

Medications

Home Made Remedies

There are a selection of home made remedies which can be used to quickly help and treat acid reflux. One of the most well known and effective options is using baking soda for heartburn.

Basically how this works is you can add half a teaspoon of baking soda to about 120ml of water and stir well and then drink. This makes an alkaline mixture which is a great for helping lower the acidity of the stomach. Read more about how baking soda works in this article.

Antacid Tablets 

These are tablets which are generally available over the counter in most countries and where you won’t need a prescription from a doctor. 

These are tablets which are designed to reduce the acid in the stomach and make it more alkaline, thus reducing the effect of any acid refluxed into the esophagus. These tablets are relatively mild when compared with some other antacid tablets that I will talk about more later on. Some examples of these medications include –

• Tums

• Rolaids

• Pepto-bismol

• Mylanta

• Maalox

• Gelusil

Gaviscon

If you haven’t already heard of Gaviscon it is typically available in a liquid form. Depending on what variant you get, their effects can be slightly different. For example the UK version of Gaviscon Advance that I recommend for people creates a foam raft on top of the stomach contents which is brilliant for preventing acid from refluxing up. 

Some other forms of Gaviscon are more focused on the alkalising effect and helping lowering the acidity similar to the tablets mentioned above. The main advantage of Gaviscon over the tablets is that raft effect on top of the stomach contents that helps prevent reflux as well as the neutralising acid effects.

Also because it is in liquid form is helps wash and neutralise any acid from the throat and the esophagus which can further help ease symptoms. Check out this out why I recommend Gaviscon Advance(UK) over the standard version of Gaviscon in this article. 

H2 Blockers / H2-Antagonists (H2As)

Arguably the next step up from the likes of the antacid tablets and Gaviscon is H2 blockers. Basically what H2 Blockers do is lower the amount of acid in the stomach thus lowering the chance of heartburn and other acid reflux symptoms. H2 blockers are a commonly used remedy for the likes of GERD. They are also used to treat the likes of gastritis, inflamed stomach or even peptic ulcers. 

Some of the most common forms of H2 blockers are –

• Ranitidine (Zantac)
• Famotidine (Calmicid, Fluxid, Pepcid AC)
• Nizatidine (Axid)
• Cimetidine (Tagamet, Tagamet HB)

H2 blockers can block acid over a longer period of time – up to 8-12 hours. This is why they are sometimes recommended for people with GERD to be taken before bedtime because of their longer protection time. How H2 blockers work is by causing a certain reaction with cells in the stomach which produce acid so that they basically aren’t able to produce as much acid.

When compared with PPIs H2 blockers are considered to be less effective at blocking acid but also much safer to take than PPIs long term. Though of course H2 Blockers have their own host of side effects, some of the common ones are –

• Constipation
• Diarrhea
• Dry mouth
• Dry skin
• Headaches
• Running nose etc.

Proton Pump Inhibitors (PPI’s)

Probably the most potent acid blockers on the market are PPIs or proton pump inhibitors. Ideally you should try to calm or reduce symptoms through the other means that I have already covered above before ever considering PPIs for treatment. PPIs are more commonly prescribed for people with severe acid reflux like GERD and even wrongly prescribed for people with silent reflux(LPR). 

For people with severe acid reflux(GERD) PPIs have shown to be quite effective at reducing symptoms, whereas for people with silent reflux(LPR) PPIs have been shown to be ineffective you can check this study for reference.     

The common forms of PPIs include –

• Omeprazole (Prilosec, Zegerid)
• Lansoprazole (Prevacid)
• Esomeprazole (Nexium)
• Pantoprazole (Protonix)
• Rabeprazole (Aciphex)
• Dexlansoprazole (Dexilant)

For people with more typical acid reflux symptoms like heartburn PPIs are more commonly prescribed than is necessary. While probably the most effective for people with normal acid reflux or GERD they also come with the most downsides and long term health problems. The longer you are taking them for the more likely you are to be affected by the downsides.

I think it’s important to let you know some of the major downsides to taking PPIs that have been backed up by studies and research alike. 

The first study I want to talk about is a Danish study which showed ones chance of developing esophageal cancer is increased when taking PPIs long term. There was also a veterans administration report that compared patients with acid reflux on H2 Blockers compared to PPIs, the death rate was 25% higher in the PPI group.

PPI have also been linked with other serious complications such as –

(click on each for the relevant study and back up to these statistics)

Kidney Disease +152%

Atrial fibrillation +98%

Heart failure +128%

Heat attacks +100%

Hip fractures +26%

Depression +138%

Esophageal cancer +120%

Esophageal dysplasia +240%

I want to make it clear that taking PPIs long term is not a good solution to someone with reflux but instead the other remedies I have mentioned above are all much better options. As a short term remedy PPIs(8 weeks per year) can be used but as a long term option it is best to consider the alternatives.

PPI Rebound Effect

One final thing that is important to mention about PPIs is the rebound effect. Let’s say you have been taking PPIs for your acid reflux for some time and you decide to stop taking them. 

If you immediately stop taking them you will likely suffer from massive acid reflux. The reason for this is because of a rebound effect of stopping them too quickly. In fact there was a study done where people who had no acid reflux took PPIs and then later stopped them just like how I explained – even these healthy people suffered from this same rebound effect even though they have no acid reflux before.

So if you want to stop taking taking PPIs is best to taper off them over a period of weeks. For example if you are taking 40mg go to 30mg then 20 then 10 then off. Each of the gaps should be about 1 week so your body has some time to adjust to the lower dosage. 

Only when you are lowering the dosage it is a good idea to supplement and take some H2 blockers and Gaviscon alongside as you are lowering the dosage. Taking the H2 blockers before each meal and before bedtime in this transition period is recommended.

H2 blockers are a much safer kind of drug that have much less side effects and complications than PPIs do. Alongside the PPIs taking the Gaviscon after meals is also an option that can be done.

Once the PPIs have been completely stopped the H2 blockers can then be tapered off in a similar sense from 4 tablets a day to 3, 2, 1 and then stopped. Similar to how you taper the PPIs you should taper off the H2 blockers so roughly 1 week per each dosage level is good. For more information – getting off PPIs and acid rebound.

Acid Reflux Surgery

Usually after exhausting all of the other options then surgery may seem like the only choice but it’s important to note that sometimes small changes to things like diet can make a massive difference. Though after that point perhaps you may want to consider surgery options. There are a selection of different options which I will cover more about below.

• Nissen Fundoplication

The nissen procedure is somewhat of the standard procedure for people with GERD. How it works is that tightens and basically reinforces the LES. This tightening will help lower/stop the chance of acid from refluxing up and out of the stomach.

The surgery is one of the more invasion surgery options. The surgeon will need to create 4-5 incisions in the abdomen. Because of it being more invasion this means more time is needed for healing. Healing time can take 2-3 months and usually patients can return to work 2-3 weeks after the operation.

How the surgery works is the top part of the stomach is wrapped around the lower part of the gullet which will basically forms a collar. The surgery as I mentioned will tighten up the LES and should help prevent acid reflux and has been shown to be successful in the long run for most people. The procedure can be reversed but it isn’t as simple to reverse as some other surgeries.

• Linx

Basically the linx works on a similar strategy just like the nissen procedure to strengthen that LES area above the stomach. How it does this though is quite different to the nissen.

How this linx works is a small magnetic band is placed above the stomach at exactly where the LES is located. This magnetic bands opens and allows food/drink to pass into the stomach and after the food/drink has entered the stomach it retracts and helps keep that LES tight and the acid inside the stomach. It’s quite simple logic and can work well.

This procedure is minimally invasive thanks to be performed using keyhole surgery and thus needs much less recovery time when compared with the likes of the Nissen. It’s finally worth mentioning that the surgery is also quite easily reversed.

• Stretta

Stretta is not like other more common surgeries. The reason being that it doesn’t require any stitches, implants or incisions. This makes it a preferable option because you can return to work the day after the surgery. 

How stretta works is that it sends a radiofrequency energy which is sent to the muscle between the stomach and the esophagus(LES). What this radiofrequency is intended to do is to remodel the muscle tissue and stimulate it. This can make the muscle stronger and more effective, and it also makes it thicker – all of which can help prevent acid reflux. For more detailed information on Stretta I recommend you check my article here.

• TIF (Transoral Incisionless Fundoplication)

This procedure creates a barrier between the stomach and the esophagus. As you might have guessed this prevents the acid from refluxing up. 

The procedure doesn’t require any incisions. A device called the EsophyX is inserted into the mouth. It will create several folds at the base of the esophagus. How this works is the folds form a new valve which should help prevent any acid reflux. If you prefer a procedure with little invasion this is one of the options to consider.

• EndoCinch Endoluminal Gastroplication Surgery

This procedure uses an endoscope. Basically how it works is that stitches are made to form pleats in the LES. This is done to strengthen the LES, and a stronger and more effective LES means less acid reflux. 

With this procedure, most people can return home on the same day and then return to work the following day. This procedure isn’t typically as common as some of the others mentioned.

Acid Reflux Diagnosis

There are multiple kinds of tests available for diagnosing acid reflux. Some are more common, whereas others are more specific for people with certain symptoms. Below I am going to cover some of the most common available options.

A Barium Swallow 

A barium swallow is a test used to help determine things like ulcers or a narrowing of the esophagus both of which can be related to acid reflux. 

Basically how the test works is you swallow a liquid solution and as the solution is swallowed and passes down your throat and your digestive system a series of x-rays are taken. The barium swallow can help reveal problems with the throat, esophagus or the stomach – the problems to be detected could be ulcers, narrowing, tumors etc.

Esophageal Manometry

The purpose of this test is to check for movement and pressure problems that may be present in the esophagus particularly the LES which can cause problems like heartburn. 

This test is typically used for people with difficulty swallowing, acid reflux symptoms or people before an anti-reflux surgery. 

How this test works is a small tube is passed up into the nose and then down the esophagus where it will measure the contractions of the esophagus on a graph. The test will last for about 30-40 minutes time.

Ph Monitoring:

There are multiple kinds of pH monitoring tests. Below I will explain a few of the most prominent ones and their differences.

Esophageal pH and Impedance Monitoring

This test is used to measure the pH of the esophagus over a period of 24 hours. Basically how this test works is a thin tube is inserted in the nose and passed down the esophagus. Over the test time the device will measure the pH of the esophagus while you do daily normal things like eating or sleeping. 

This is a good test for determining the likes of GERD and heartburn like symptoms. Though is not a reliable test for silent reflux (LPR) because it doesn’t detect gaseous reflux which is the main reason for silent reflux. 

Luckily there is a test which is much better for people with silent reflux called the Dx-pH test or Restech test which I will cover below. If you have both GERD and LPR symptoms it would be best to go for the Dx-pH test. 

Bravo Wireless Esophageal pH Monitoring 

The bravo pH test is similar kind of test as the esophageal pH monitoring test – it is best to detect GERD but is not reliable for detecting LPR/silent reflux. 

How it works is basically a small capsule is attached to the wall of your esophagus during an upper endoscopy. Basically the capsule transmits signals to a receiver which measures the pH of your esophagus usually during a period of 48 hours. After about 3-7 days the capsule will fall off the side of the esophagus and will pass through your digestive system. 

Dx-pH Test (Restech test)  

If you are suffering from primarily throat symptoms and believe you have silent reflux(LPR) then the best test for you is the Dx-pH test. 

It is set up like the esophageal pH and impedance monitoring test where a thin tube is put up the nose and down the throat and into the esophagus. It is the best test for people with LPR because its probe which measures the pH(acidity level) is much more sensitive than the esophageal pH test and can detect gaseous reflux which is the primary cause of the silent reflux, that of which the esophageal test is highly unreliable at doing and shouldn’t be used for that situation. You can read more about this test here.

Endoscopy 

One of the more common tests for acid reflux is the endoscopy. This involves a long flexible tube being inserted down the throat with a camera at the end. 

When the camera is down the doctor can check for any problems in your esophagus and stomach. 

Before the test begins the throat will be sprayed with anesthetic to numb the throat and make you more comfortable. The test should be very fast once it begins lasting only minutes at most.