Understanding Acidity: Causes and Health impact
ACID IN OUR STOMACH
We sometimes suffer from a burning feeling in our stomach or lower chest, sensations we often describe as ‘acidity’ or ‘heart burn’. The stomach is the organ of our digestive system which produces acid (Hydrochloric acid). The acid is of importance as it is required for digesting proteins as well as destroying a number of harmful germs and infective organisms which come into our body by way of food/mouth.
Some amount of ‘basal acid’ is always present in the stomach, while the acid release is greatly stepped up during stimulation by seeing/smelling/tasting food, around meal time due to conditioning, when protein substances from food enter the stomach, and during Stress. ‘Acidity’ can occur due to 4 mechanisms or their combination:
Increased presence of acid in Stomach–
This can happen if one does not eat when hungry or during conditioned meal times, or tends to eat hurriedly, irregularly or under pressure. Acid production is also increased during and due to physical or mental stress, as well as anxiety, therefore is a common problem seen in the professional and working population. (ZE syndrome is a very rare condition where a stomach tumor causes hyper stimulation of acid production)
Acid refluxing back into the food pipe (Esophagus) –
Where the food pipe enters the stomach, there is a valve like mechanism called the LES (Lower Esophageal Sphincter) which prevents stomach contents from refluxing back into our food pipe (esophagus). Laxity or incompetence of this sphincter can cause acid to reflux back in food pipe to cause Heartburn and feeling of acid regurgitation/backlash in mouth (called Gastro Esophageal Reflux Disease (GERD), also called Reflux Esophagitis) along with belching, acidic taste in mouth and hoarseness.
Increase in weight/obesity and sedentary lifestyle can increase LES pressure, making it more lax, and thereby predisposing to acid reflux. Symptoms are often worse at night as lying down to sleep, causes the LES to relax, minimize swallowing and remove the advantage of gravity pushing food down. Some symptom relief is obtained by sleeping in propped up position.
Slow emptying out of Stomach contents-
Sometimes the movement of the food from stomach to duodenum maybe slow (gastric hypo-motility) resulting in more prolonged exposure of stomach lining cells to the food and acid (decreased acid clearance), along with increased chances of reflux into the food pipe. In such patients there may be symptoms like early satiety (feeling full prematurely before completing meal), post prandial fullness and/or bloating (feeling full/uncomfortable just after a meal, and/or otherwise, respectively) and sometimes nausea. People with diabetes, tendency to constipation, or depression more commonly have gastric hypo-motility.
The term Dyspepsia (commonly called Indigestion) is used to describe the feeling of discomfort in the stomach which can include feeling of acidity, or fullness/bloating, or a combination of these symptoms. In the absence of any specific cause found for these symptoms, the condition is often called Functional Dyspepsia.
Damage to Stomach lining cells –
This can happen on eating irritant or highly spicy foods which causes inflammation and injury of the stomach lining cells (Gastritis). Such damage can also be seen with too much or long term exposure to highly acidic food/beverage items or smoking.
Steroid medicines decrease production of the protective mucus and also increase acid secretion especially in response to stress. NSAID (like aspirin, ibuprofen, diclofenac etc) medicines block production of protective substances called Prostaglandins which also increase the damage to stomach lining by acid.
‘Helicobacter pylori’ are bacteria that can be present in the stomach and cause inflammation and damage of the lining cells.
ULCERS AND ACIDITY
Ulcers occur due to acid induced damage and discontinuity of the lining of the lower part of food pipe in GERD (Erosive Esophagitis), stomach (also called Gastric ulcers), and sometimes the first part of small intestine (Duodenal ulcers) which is also exposed to the stomach acid. These ulcers manifest as acidity symptoms and burning pain, which maybe aggravated or relieved by meals depending on the location. Sometimes an ulcer may perforate through which can cause severe pain, massive bleeding and infection, while the aftermath scarring can cause a stricture (narrowing/obstruction) leading to difficulty in passage of food.
Sometimes during a stressful episode like hospitalization/prolonged illness or post-surgery, there is damage to the stomach lining cells, decreased capacity to produce mucus, and stress induced increased acid production all leading to development of ‘stress ulcers’ in the stomach.
Acid Peptic Disease is an umbrella term to include GERD, Gastritis, Ulcers (Esophageal, gastric, duodenal) and the rare ZE syndrome, that is all conditions caused by acid induced damage.
Alarm or Red flag signs– Recurrent vomiting episodes, blood in vomit, weight loss, weakness or paleness, difficulty in swallowing with a feeling of feed getting stuck in the chest, feeling a lump in stomach area and severe abdominal pain. Presence of any of these should prompt an immediate consult.
Health Solutions for Acidity
The solution lies in implementing diet and lifestyle modifications and assessing response after 3 months. Medicines can be additionally taken in case of inadequate response, severe symptoms, diagnosis of ulcers or during a short defined period of stress.
If you tend to suffer from acidity symptoms recurrently or over a prolonged period, a relook at your diet and eating patterns is recommended. Diet consists of Reducing, and Restricting consumption of certain foods while including more of certain other food items.
Main meals should be taken at regular time with a small snack every 2-3 hours (one between breakfast and lunch, and one between lunch and dinner – mid evening). Keep a gap of minimum 2 hours between lying down/bedtime and dinner.
Avoid skipping meals, unduly delaying meals, or having hurried meals. Chew thoroughly and enjoy your food. Avoid gulping down food with water.
Include half hour of exercise (5 days/week) in your lifestyle – swimming, brisk walking, cycling, jogging, yoga, or aerobics. If sitting for prolonged periods of time, take a short walk and do some stretching every 2 hours.
Adequate and good quality sleep is the best natural de-stressor. However, including relaxation techniques in daily routine can reduce unwanted acid stimulation like deep breathing exercises, indulging in hobbies like reading, music, dance, gardening, sports, crafts-work, and time with family-friends.
Medicines for Acidity – Addressing Concerns
Medicines for Acidity are loosely clubbed as Antacids. These maybe drugs to suppress acid production, or act by other ways to provide symptomatic relief. Before starting medicines, or based on response to medicines, investigations like Endoscopy and testing for Helicobacter pylori infection may be performed to visualize presence of ulcers and confirm diagnosis
Acid Production Suppressors
Medicines to suppress Acid production can act against 3 important steps in acid production:
Proton Pump Inhibitors (PPIs)
These medicines act directly on the final step of acid production and have become the most prescribed and used medicines in acidity especially GERD and peptic ulcers. They should be used if acidity symptoms are severe, prolonged or non-responsive to lifestyle-diet modifications. They are the drugs of choice when an ulcer has been diagnosed, in order to aid in its healing and prevent complications or relapse. They are also the drugs co-prescribed with the NSAID class of drugs used for pain and inflammation (aspirin/ibuprofen/diclofenac etc), and along with antibiotics for Helicobacter pylori infection.
Available PPIs include Pantoprazole, Rabeprazole, Esomeprazole, Omeprazole, Lanzoprazole, Dexlanzoprazole, and Ilaprazole
PPIs are given once a day usually half hour before breakfast or dinner depending on prominence of symptoms during day or night. They may be given twice a day to give better acid suppression for ulcer healing or to prevent night time acidity (called- nocturnal acid breakthrough NAB). They are usually given for 4-8 weeks, followed sometimes by another 4-8 weeks if response is inadequate, and thereafter at a maintenance dose for up to 6 months.
Concerns – There have recently been a number of health risks sighted with long term and continuous use of PPIs (over 1-2 years). Ideally PPI use should not be continuous beyond 6 months at which point no health concerns have been seen. If taking beyond 8 weeks, it would be prudent to test regularly for Kidney function parameters, magnesium, calcium and B12 deficiency, and screen for Osteoporosis (low bone mass/bone thinning) and Bowel infections.
H2 Histamine blockers
These medicines prevent the stimulation of acid production in the stomach by a substance called Histamine. They are taken once or twice a day and are ideal for tiding over short symptomatic periods of acidity due to irregular meals, gastritis, and stress. Commonly used ones are Ranitidine and Famotidine. They may also be added at bedtime in patients taking PPIs, to give effective basal acid suppression through the night or enhance healing of ulcers.
Concerns – Though no long term health risks have been reported with H2 Antihistamines, recently many brands of Ranitidine were detected to contain amounts of NDMA, a substance known to cause cancer in animals and a probable human carcinogen. NDMA is also found in similar or higher amounts in the environment, industrial waste and food items like meat, fish, beer and tobacco smoke. This chemical has been found in higher levels in another drug Valsartan (for high BP) recently. Due to this, many manufacturing companies have spontaneously recalled their Ranitidine brands. As of now the USFDA has asked the manufacturers to conduct proper tests to estimate accurate NDMA levels in their Ranitidine brands and set the limit of 96ng/day (or 0.32 ppm) for recalling brands. It has not yet put out any recommendations or restriction on doctors or patients for prescribing or taking Ranitidine but suggests considering other acid suppressant drug options available.
Other medicines for Acidity
Acid neutralizers containing alkaline bicarbonate and hydroxide salts are available as liquid or chewable preparations over the counter. The provide some temporary and short term relief.
Medicines to protect the stomach lining are also available and may sometimes be co-prescribed like coating agent –Sodium alginate especially combined with acid neutralizing agents. Medicines which increase stomach mucus and protective Prostaglandins (Sucralfate, CBS and Misoprostol), are now not prescribed often due to multiple dosing and unpleasant side effects.
If symptoms suggest decreased gastric motility like bloating, fullness or nausea, agents called ‘Prokinetics’ are added to the treatment which act by increasing the motility of the stomach as well as increasing the tone of the LES. These include medicines like Domperidone, Itopride, Acotiamide and Levosulpiride.
If psychological cause or stress is a likely cause of acidity, appropriate Antianxiety-Antidepressant medicines may also be added to the treatment regimen under adequate medical monitoring.
Antibiotics (like Amoxicillin, Clarithromycin or Metronidazole) may be added to the PPI for the initial week in case a Helicobacter pylori infection is to be treated.
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