How to achieve acid reflux relief without any medication?

Symptoms of acid reflux usually respond to dietary and lifestyle modifications. These changes in diet and lifestyle are meant to accomplish specific goals. The main guide to apply these measures is understanding the normal aspects of esophageal and stomach functioning in addition to the common causative mechanisms underlying acid reflux disease.
The following points will cover, in a process oriented action model, the reasons for most of the practices that should be adopted in the treatment of heartburn.

1- Assisting natural processes which promote acid clearance and stomach emptying

Increasing the production of saliva: saliva is produced by the salivary glands located around the mouth and have a high bicarbonate content and therefore an alkaline reaction. One of the functions of saliva is to neutralize the acid accidentally refluxed into the esophagus. Smoking and salty snacks reduce saliva and contribute to heartburn, they should therefore be avoided. At the same time, chewing gum should be encouraged as a good habit for heartburn sufferers who complain of dryness of the mouth.

Chewing thoroughly: mechanical degradation of food is an important preparatory step prior to digestion as it prepares food for further digestion in the stomach. Eating quickly is a bad habit that results in large food particles which imposes more work activity upon the stomach in the form of increased motility and increased acid production. It thus stays for a longer time in the stomach and delays its emptying. all these factors predispose to acid reflux and the habit of eating quickly should therefore be discouraged.

Small meals: a small meal would be digested easily with small amounts of acid and enzymes produced by the stomach. It is also cleared rapidly and does not increase pressure inside the stomach, consequently favorable circumstances for reflux are minimized. On the other hand a large meal is associated with increased production of acid, increased pressure and distension and delayed emptying of the stomach. all these factors initiate reflux and large meals should be avoided.

Drinking water: water dilutes and washes acid refluxed into the esophagus and promotes its clearance. At the same time it accelerates stomach emptying and prevents reflux. Drinking water should thus be encouraged before and after meals.

Pro-gravity postures: the erect posture favors movement of refluxed acid back into the stomach by the effect of gravity. On the contrary lying down is an anti-gravity posture, this fact should be considered together with our knowledge of the location of the esophagus, mainly within the chest (with negative pressure) and the location of the stomach, inside the abdomen (with positive pressure) these factors favor flow towards the esophagus and hinders esophageal clearance. Another factor related to posture is the increased tone of muscles supporting the lower esophageal sphincter in the upright position, this support is abolished when lying down as these muscles relax. Practically speaking recumbency should be avoided for at least 3 hours after eating, one should not go to bed immediately after meals and in heartburn sufferers the head of the bed should be elevated about 6 inches to prevent reflux.

Increasing lower esophageal sphincter pressure: from the functional point of view, high protein diet stimulates gastrin production, a local hormone that increases the sphincteric pressure and prevents reflux. Anatomically, a healthy physical built maintains an optimum tone in the muscles supporting the lower esophageal sphincter. It's well known that obesity weakens body musculature and reduces its contractility. Accordingly, we should maintain a desirable body weight and a low-calorie diet can be used to promote weight loss if needed. a high protein diet is also recommended.

Promoting stomach emptying: an important function regulating pressure inside the stomach and the amount of acid produced. Whenever emptying is delayed significantly food, acid and enzymes accumulate inside the stomach resulting in increased pressure and distention in addition to increased acid volume. The rate of stomach emptying is proportional to the rate of completion of digestion of a certain amount of food. Accordingly, when the digestive load is increased as following a heavy meal or swallowing large food particles or particularly when the meal is mostly composed of fat, a longer time is needed for digestion and consequently emptying is delayed. Drinking water also promotes stomach emptying. The role of having small meals, chewing thoroughly, low fat diet and drinking water before and after meals should be overstressed.

2- Eliminating factors that initiate reflux into esophagus

Direct irritation of the surface lining the esophageal lumen: avoid citrus,onions, spices and acids from tomatoes

Increased relaxation of the lower esophageal sphincter: avoid eating foods and drinking beverages that reduce sphincter pressure such as:
Beverages:
Caffeinated, carbonated or alcoholic beverages
Citrus-based juices
Food ingredients:
Vinegar, spices, garlic, onion, tomato-based products and peppermint
Vegetables: raw onion and tomatoes
Citrus fruits: orange, lemon, grapefruit
Fatty meals: salad dressing and fried food
Dairy products: sour cream, milk shake, ice cream and cottage cheese
Sweets and desserts: chocolate and potato chips
Medications: avoid medications that lower sphincteric pressure such as: Theophylline, Anticholinergics, Progesterone, Calcium channel blockers, Alpha adrenergic antagonists, Diazepam and Meperidine.

Increased acid production: avoid heavy meals, spices and alcohol.

Increased pressure inside the stomach: avoid practices associated with increasing pressure. These originate either from within the stomach (internal) or from the outside (external). Internal pressures are generated following delayed gastric emptying associated with heavy meals with high fat content or secondary to obstruction of the stomach outlet.
External pressures are mostly due to compressive forces associated with practicing exercise following meals especially vigorous exercise with bending movements. Tight clothing also exerts external compression upon the stomach and heartburn sufferers should wear loose-fitting clothing. Obesity is also considered a compressive factor as it increases the bulk of viscera inside the abdomen and weight loss should be encouraged.

To summarize, the best measures for acid reflux relief are:
Understanding normal functions of the esophagus and stomach.
Enhancing normal functional mechanisms.
Avoiding foods, medications, and lifestyle practices which disturb normal functions and cause acid reflux.

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What relieves symptoms of acid reflux?
Lifestyle changes can prevent reflux
Preventive measures for acid reflux relief: avoid smoking
Preventive measures for acid reflux relief: avoid alcohol

A special advice on fatty meals for acid reflux relief

Why fatty meals out of all foods that cause acid reflux?
Fatty meals are considered the most aggravating foods that can cause or worsen heartburn. They are widely used as an additive ingredient or a frying medium in the cooking process of most meals. They also make food more palatable, having a special flavor. Fats in addition are a common constituent of delicious milk products as ice cream and favorable sweets like dough-nut which we all like.
Their contribution to acid reflux is multi-factorial. They are known to lower resting pressures of the lower esophageal sphincter and cause its relaxation resulting in acid reflux. Fatty foods release enterogastrone, a local hormone that inhibits motility of the stomach, consequently food stays longer and pressure builds up inside the stomach with the increased possibility of reflux. As they keep food longer, it stimulates the production of more acid and digestive enzymes.
People, used to consume large amounts of fat are also obese and that adds more to the risk.
So how to reduce fat in our meals?
1- Choosing the source of protein: fish and poultry should be the preferred proteins of animal source and dry beans or peas the source of plant proteins. Don't forget to remove poultry's skin before cooking.
2- Choosing the way of cooking: boiling and broiling instead of frying.
3- Choosing low fat versions: skimmed milk instead of whole milk
Avoid ground beef, chicken nuggets, buffalo wings, smashed potato, french fries, cottage cheese and corn chips.
Make up your mind and relieve your heartburn.

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How to achieve acid reflux relief without any medication?

Achieving acid reflux relief with surgery

The frequency of heartburn is the main factor that should be considered in determining the best treatment. Heartburn may be infrequent, frequent or persistent. Infrequent bouts usually respond to lifestyle modifications and traditional OTC medications. Frequent heartburn is mostly relieved with proton pump inhibitors. On the other hand when heartburn is persistent the situation is different as it is considered a warning sign of acid reflux disease.
In view of the fact that the natural history of esophageal damage caused by acid reflux can involve rare and serious consequences, other treatment options should be seriously considered. Actually, surgery is being reserved for those who can develop serious complications.
But how can we select those who are more susceptible to complications?
1- By documenting the presence of visible changes in the appearance of the surface lining the esophagus.
2- By documenting that the cause of these changes is mostly attributable to acid reflux.
3- By documenting the association of lower esophageal sphincter motility functional disturbance.
These would be translated into Endoscopy, 24-hour esophageal acid monitoring and esophageal manometry respectively.
The aim of these procedures is to confirm the cause- effect relationship in the heartburn sufferer, and together with failure of medications to relieve symptoms (as revealed by the need for continuous drug treatment or of increasing doses of medication) would be an indication for surgery. Other factors related to failure of medical treatment include: non compliance with drug therapy, the financial burden of medications and the preference for surgery especially in young patients.
The purpose of surgery is to ensure the intra-abdominal location of the lower esophageal segment which has the lower esophageal sphincter at its lower end. That would keep it positioned where a positive (intra-abdominal) pressure is maintained.
The diaphragmatic opening through which the lower esophagus passes is also narrowed and the top part of the stomach (called fundus) is wrapped around the lower esophagus and sutured to itself to tighten lower esophageal end.

This operation is called Nissen Fundoplication and is considered the most effective and proven procedure.
Recently, innovative techniques have allowed surgeons to perform this operation laparoscopically. It takes about 90 minutes and improves symptoms in 90% of patients. The operation may reverse damage caused by acid reflux disease and patients may be able to stop medications completely. However, it has been reported that after 5 years some patients would require proton pump inhibitors to control symptoms.
The operation may also be associated with some complications as difficulty in swallowing, inability to vomit and failure to completely relieve reflux symptoms.
Patient selection is the key to effectiveness of this operation and should mainly be indicated on the basis of patient preference.
If Hiatal Hernia or frequent pulmonary aspiration is associated with acid reflux disease they add more indications for the operation and results are much improved.
Always consult your physician to determine if surgery is an appropriate option for you.

Mechanisms of acid reflux

The central mechanism in acid reflux disease is disturbed acid clearance. Acid is produced in the stomach, and as long as its rate of clearance from the stomach into the small intestine is normal, it will not accumulate in the stomach and reflux into the esophagus. An example of a disorder that hinders clearance of acid from the stomach is obstruction of its outlet resulting in an increased pressure inside the stomach.
At certain circumstances during daily activities some acid may normally regurgitate from the stomach into the esophagus. Again acid clearance back into the stomach is accomplished by gravity and the esophageal propulsive movement towards the stomach. Accordingly any disturbance of esophageal motility would affect its acid clearance mechanism.
Role of the lower esophageal sphincter:
The sphincter is anatomically configured and functionally organized to act like a valve allowing one way movement of swallowed substances from the esophagus into the stomach. anatomical disturbances such as Hiatal Hernia and functional disorders as incompetence or transient relaxation would favor acid reflux.
These are the main primary factors involved in causation and are mostly electromechanical.
Secondary factors actually operate after reflux and are meant to prevent esophagitis. They are mainly chemical and include saliva and the bicarbonate content of the glandular secretions on the inner surface of the esophagus.
All these factors should be well investigated when acid reflux relief is considered.

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About heartburn
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Acid reflux relief prevents complications

Why should you treat heartburn?
The goal of treatment is not only to relieve the symptom of heartburn. Of course symptomatic treatment would be all that is needed when heartburn is not associated with acid reflux disease. That means in the functional stage or when there is acid reflux alone.
When the disease develops (the organic stage) with changes of esophagitis diagnosed by the physician, the aim is to heal or cure these changes simply because all the complications of acid reflux disease are a sequel of untreated esophagitis. To avoid such complications as ulcers, strictures, Barrett's esophagus or even cancer you should start treatment. The use of proton pump inhibitors for example reduces acid production and promote healing of esophagitis since acid is its main causative factor.

The role of Proton Pump Inhibitors in acid reflux relief

What are proton pump inhibitors?
A pump is a utility that moves a substance against a gradient.
A well known example is the water pump which lifts water up against gravity.
In our case, there are cells in the membrane lining the stomach lumen, these cells produce acid and pump it against the concentration gradient set by the previously formed acid into the stomach lumen.
That means the concentration of acid in the stomach lumen is higher than that inside the cell and this gradient would favor movement of acid into the cell; however the cellular wall prevents this and at the same time pumps more acid into the lumen.
Just like the water pump needs electric enrgy to lift water upwards; the cellular wall utilizes chemical energy to pump acid outwards.
Acid is produced in the form of a positively charged subatomic particle called proton. The proton is the nucleus of the lightest chemical element, hydrogen. Actually the hydrogen atom consists of a proton as the nucleus, to which a negatively charged single electron is bound as opposite charges attract. Because the proton is 1836 times heavier than the electron, the proton is considered to constitute almost the entire mass of the hydrogen atom.
So how proton pump inhibitors affect this mechanism?
They accumulate on the luminal surface of the acid producing cells and inhibit the enzymes involved in the process of synthesis of chemical energy , essential for the pumping action.
Consequently; no energy, no pump activity and no acid production (no proton flow into the lumen of the stomach).
The above figure illustrates this cellular mechanism and also shows the receptor sites at which signals triggering acid secretion interact. These triggers are Histamine, Gastrin and Acetylcholine. They are chemical substances delivered around acid producing cells and are released from local cells, intestinal cells or nerve endings.

The above figure also demonstrates how the acid pump is blocked and acid production consequently inhibited.
Examples of Proton Pump Inhibitors:
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Pantaprazole (Protonix)
Esomeprazole (Nexium)
Proton Pump Inhibitors are used for both diagnosis and treatment. In the Omeprazole test: a dose of 40mg is given in the morning and another 20mg in the evening for 7days to a heartburn sufferer. If symptoms are relieved following this regimen, the diagnosis of acid reflux is confirmed. It is considered a noninvasive and easily available test with reasonable cost.
For acid reflux relief, they are considered the most effective agents and the standard medical therapy. All of them are effective but response may vary from patient to patient.Proper timing of intake is critical for efficacy, it should be 30minutes before breakfast or other large meal. For some patients with partial response or severe symptoms, the physician may advice a second additional dose before the evening meal. Being long acting (duration of action of a single dose is 24hours), they allow time for damaged tissues to heal. They have a healing rate of 80% in moderate to severe cases and relief of symptoms in up to 90% of patients. In comparison to Histamine type2 receptor antagonists, they are more effective and faster in promoting healing.

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What relieves symptoms of acid reflux?

Short term relief of acid reflux symptoms is easy. The problem is that the disease relapses, and many sufferers will require long term management.
There are general considerations that should be applied. These include: reducing acid, enhancing esophageal clearance and correcting anatomical or physiological defects.
Antacids are used for short term relieve only. H2 blockers are also effective. Proton pump inhibitors have become the mainstay in acid reflux treatment. They could be used effectively for continuous therapy in complicated cases.
Enhancing clearance and promoting mucosal defense could be attempted by such drugs as: Prokinetics, Alginates, Antacids and Mucosal protectants. These trials are practically not convincing.
Correcting anatomical or physiological defects as Hiatal Henia and lower esophageal sphincter incompetence should be considered following diagnosis of these problems. The commonly used operation is Fundoplication. The hernia is reduced, the normal position of the sphincter is restored and consequently lower esophageal sphincter competence is reinforced. However, some complications may follow this operation such as difficulty in swallowing and inability to belch or vomit. The results would be much better with good selection of patients.

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Acid reflux and bronchial asthma

Is there any relationship between heartburn and asthma?
Bronchial asthma may cause acid reflux disease and heartburn:
Mechanically by air trapping associated with bronchial asthma which results in flattening of the diaphragm. As the lower esophageal sphincter is surrounded by diaphragmatic muscle fibers, their weakened support increases relaxation of the sphincter and promotes reflux.
Chemically by drugs commonly used for treatment of asthma:
Theophylline increases gastric secretion and relaxes sphincter
Albuterol also relaxes lower esophageal sphincter.
On the other hand, Acid reflux may cause bronchial asthma:
Reflux may induce reflex bronchial spasm
Acid may be aspirated in minimal amounts and initiate broncho-constriction
Inflammation of the upper respiratory tract associated with reflux releases chemical substances which mediate bronchospasm.
About 75% of patients with asthma have acid reflux disease. Reflux symptoms usually precede attacks of wheezy chest. Asthma is also initiated by the same dietary and lifestyle factors which trigger acid reflux symptoms. There is a good response to proton pump inhibitors given twice daily and treatment should continue for at least two months.

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Progress of acid reflux disease

Untreated acid reflux is a progressive disease. Early stages characterized by episodes of heartburn are not associated with any signs of damage. later on signs of inflammation of the esophagus (esophagitis) are evident.
Barrett's esophagus is a warning sign because it is considered a precancrous stage. To understand Barrett we should recall the normal cellular lining of the esophageal lumen which is a specialized type with characteristic number, shape and cell arrangement. This particular type is partly replaced by a cellular pattern characteristic of intestinal lining membrane. Such a cellular modification is a sort of adaptation to damage induced by acid reflux.
Later on acid reflux disease may be complicated by malignant transformation or cancer on top of Barrett's esophagus called Adenocarcinoma.
To summarize:
Acid reflux: only symptoms(e.g heart burn).
Acid reflux disease: evidence of esophageal damage.
Complicated reflux disease: Barret's esophagus which may result in cancer.

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Lifestyle changes can prevent reflux

It is well known that modifying lifestyle would reduce symptoms of acid reflux disease. The main effect is accomplished by minimizing exposure to factors that interfere with the normal function of the lower esophageal sphincter. Meals should be taken at least two hours before bed time to prevent regurgitation of stomach acids into the esophagus. Avoiding exercise immediately after meals would prevent generating forces that increases stomach pressure, also exercise would be associated with kinking of the full stomach. Obesity is another important factor and the heartburn sufferer should be encouraged to maintain a healthy body weight. Tight clothing, by squeezing the stomach would induce reflux of its contents into the esophagus and should be avoided. Reflux is usually experienced during sleep, and elevating the head of the bed will allow gravity to do its job. Stress has long been linked to aggravating reflux symptoms through many mechanisms. In an effort to cope with disruption in routine, caused by stress, unhealthy lifestyles become evident. Stress also depresses immunity state and predisposes to complications in acid reflux disease. It should therefore be alleviated by all means.

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Esophageal defenses against reflux

With all these normal daily activities that would trigger regurgitation, the esophagus seems to be highly exposed to reflux?
Actually the esophagus has many defenses against acid reflux and its consequences. Anatomical barriers in the form of muscles inside and outside(diaphragmatic) the wall of the esophagus enforce its lower sphincter to prevent reflux. Acid clearance from the lumen of the esophagus is mechanically assisted by gravity and its propulsive movement towards the stomach. Acid is chemically antagonized by saliva and the esophageal gland secretion.
The third mechanism against reflux is tissue resistance. It includes the bicarbonate content of the glandular secretions on the surface of the esophagus; the tight junctions between cells lining its lumen and the normal blood flow in the wall of the esophagus.
These defenses would be efficient only in cases of mild infrequent reflux.

About heartburn

What is heartburn?
When acidic stomach juices flow backward into the esophagus a burning discomfort is felt in the mid-chest, behind the breastbone. This is the mechanism of causation of heartburn.
But why acid flows backward?
The esophagus is a tube-like structure that connects the pharynx to the stomach and acts as a passage way for food. This flow is normally uni-directional towards the stomach and the esophagus by virtue of its lower sphincter prevents backflow.
The lower esophageal sphincter acts like a valve that keeps acid in the stomach and out of the esophagus. If the normally contracted muscle relaxes the stomach acid flows backward into the esophagus.
So what are the causes of relaxation of the lower esophageal sphincter?
Some medications and food are responsible, these include: chocolate, caffeine, fatty or spicy food, onions, mint and alcohol. Acidic foods and vegetables are also considered.
Acid reflux relief could thus be prevented by avoiding such medications and food that relax the lower esophageal sphincter.

Preventive measures for acid reflux relief: avoid smoking

Why does smoking aggravates acid reflux symptoms?
Smoking reduces the production of saliva which neutralizes acid, at the same time it increases acid secretion, in addition to these factors related to acid; smoking would increase relaxation of the lower esophageal sphincter.

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Causes of acid reflux

What are the causes of acid reflux?
There are individual variations but common mechanisms include:
The relaxation of the lower esophageal sphincter
Increasing the amount of acid produced by the stomach
Increasing the stomach pressure
Making the esophagus more sensitive to the irritating effect of stomach acid.
Acid reflux relief deals with all these causes attempting to correct them.

Heartburn vs GERD

What is the difference between heartburn and GERD?
Heartburn is a symptom (an unpleasant sensation experienced by a patient)
GERD on the other hand is a disease with changes in function and/or appearance of the esophagus.
G: Gastro (related to the stomach); E: Esophageal; R: Reflux and D: Disease.

Acid reflux disease in pregnancy

Why acid reflux is common in pregnancy?
During pregnancy there is an increased level of progesterone (a hormone produced by the ovaries); this hormone increases relaxation of the lower esophageal sphincter. Also the growth of a baby inside the womb increases pressure upon the stomach. This pressure in turn induces regurgitation of acid into the esophagus. Such a mechanical effect is of course commonest during the third trimester.

Preventive measures for acid reflux relief: avoid alcohol

Why does alcohol increase acid reflux?
Alcohol would augment acid production and increase sensitivity of the esophagus to acid.
In addition it increases relaxation of the lower esophageal sphincter and disturbs motility of the esophagus.

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How to achieve acid reflux relief without any medication?

Acid production in the stomach

But acid is normally produced in the stomach without heartburn?
Yes; the stomach is full of acid; but is built to handle it and is protected by a specialized barrier of mucus and cell wall. The esophagus on the other hand is not well protected from the injurious effect of acid and results in a burning sensation when acid regurgitates into the esophagus.

Constituents of the reflux

Is it only the acid produced by the stomach that causes heartburn?
Not only the acid is responsible for damage in the lining surface of the esophageal lumen. Other factors include: Pepsin, the digestive enzyme also produced in the stomach that digests protein in the diet; Bile acids, detergents excreted by the liver into the small intestine to digest fat; and proteases, digestive enzymes produced by the pancreas that further digest dietary protein.
Pepsin significantly damages the esophagus.
Bile acids also can cause damage especially when acid secretion is suppressed.
A mixture of acid and bile reflux was found to be more aggressive to the esophagus than acid alone.
These contents of the small intestine reflux into the stomach and then up into the esophagus.
It's important to counteract the effects of these chemical factors by various measures in order to achieve acid reflux relief.