Need a specialist London Gastroenterologist for IBS, acid-reflux etc.?
Gut symptoms whether acid reflux, bloating, diarrhoea, constipation or tummy cramps can be hugely frustrating and make life a misery. It can be very difficult to get straightforward advice about what tests might be needed, what to do and how to get your life back.
We offer several ways to help you:
- If you need help and would like to see a London Teaching Hospital senior consultant, please contact us. (Dr. John Meenan, Guy's & St. Thomas' Hospital, London Bridge Hospital; most appointments within 24 hours, before or after work hours. "Preferred/Fee Assured Provider" for BUPA, AXA and all major insurance companies).
- If you would like to see a Specialist Dietitian/Nutritionist, there is a direct link for you.
- Maybe you just want a very affordable way of managing your IBS with specialist diets and information targeted to your symptoms. We have an on-line educational and diet programme that you can start today.
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If you have IBS, try out our free Symptom Tracker
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Feel free to learn some more about Acid-reflux / GERD or IBS through the tabs above. Or, for a quick look at Acid-reflux, scroll on down this page...
Acid reflux / GERD
Acid-reflux is extremely common and extremely frustrating for many of us. The strange thing is it affects all the wrong people! If you Google it, classically it's all about overweight people on fatty diets who drink too much. But, the many of people who get it it are young, thin and eat a pretty healthy diet. So, what's going on?
The symptoms
The commonest symptom is burning behind the lower breast-bone ("heartburn"), but a good number of people get atypical symptoms such as the feeling of something stuck in their throat (called "globus"), change in voice, damaged tooth enamel or odd chest pains. What causes these problems is acid being in the wrong place. This acid does not necessarily do any damage (and usually doesn't), but the body senses it and doesn't like it.
For some people the symptoms come on after eating a rich meal, drinking alcohol (especially prosecco/champagne) or having a late meal before going to bed. That's easy, you know what to do, but, many others get symptoms no matter what they eat or do and they keep happening.
Why the reflux?
You need to understand the anatomy of the stomach and gullet (proper name oesophagus) to see why it all happens.
Firstly, the job of the oesophagus is purely to be like a boa-constrictor and squeeze food along from the mouth, down to the stomach. So two important things: (a) the oesophagus is a long, hollow tube of muscle and (b) its lining is not made for dealing with acid.
Secondly, the job of the stomach is to churn food with acid, turning it into a "soup" that can be slowly broken down and absorbed as it makes its way down along the next bit of gut, the small intestine ("small" because it's narrow, it's about 5 metres long). So, the lining of the stomach is made to tolerate acid.
This all means that if the junction between the oesophagus and the stomach doesn't function properly, acid can flow back up- "reflux". So, why might the junction not work properly? Two possible reasons, but, more anatomy first.
The chest is sealed off from the abdomen by a big "canvas" of muscle called the diaphragm. This is a bit of a design problem though, as the oesophagus has to be able to get down to the stomach and the big blood vessels have to be able to get up and down from the heart. To allow all of this "pipe-work", there is a tear-drop shaped space in the middle of the diaphragm called a "hiatus". In many people, this hiatus is slightly too wide. Not a problem in it's own right, but, it does allow maybe an inch or so of the stomach to slide up and down. This can allow acid to leak upwards. On this point and to explain a phrase that you may come across, when part of the body slides out of its proper position it is called a "hernia"- hence all of this is called a "hiatus hernia". It is quite different by the way from hernias elsewhere in the body which can get "stuck" and so need surgery; a hiatus hernia almost never gets stuck.
Not everyone with reflux has a hiatus hernia though. For many people it is another problem. More anatomy, I'm afraid!
As we know the oesophagus is a long tube of muscle and all muscle has "tone". With the oesophagus, the lowest inch or so, just before where it joins with the stomach, has increased tone which keeps it tight shut, only opening when food is coming down. The problem is that in may people this area can relax at the wrong time, when the stomach has started producing all its acid- so called "inappropriate relaxation". Nobody knows why it happens, but it is a problem.
The other thing to throw into the mix is gravity. When you're standing everything drains downwards but go to bed and then your oesophagus, the stomach and its acid contents are all on the same level. You wake up!
The message from all of this is that the key causes of acid reflux are "mechanical" problems; the machinery is not working. No surprise then that when reflux starts to happen it just keeps on going for 7 people out of 10. As to why it should start in the first place, nobody has a clue which doesn't help the level of frustration caused by all of this.
Why do some foods worsen things?
Two things to know to understand the impact that food type has on reflux: (a) if rich foods could go straight through to the small intestine, we would all end up with bad cramps and diarrhoea. The flow needs to be slowed and regulated; (b) the stomach can sense what type of food is there.
When the stomach senses oily foods (pizza, finest olive oil, fish & chips all the same to it!), alcohol, caffeine and chocolate, or if there is nicotine about, it slows down, leaving us with a noxious, acidic soup ready to spill over back up into the oesophagus.
Does reflux cause any long-term problems?
Short answer: for the majority of people, no.
Long answer, exposing the lower oesophagus to acid reflux over many years can cause scarring with narrowing of the gullet leading to problems with swallowing ("dysphagia"). Also, in about 5 people out of every 100 with long-term reflux, the cells lining the lower oesophagus can change to protect themselves from the acid. This is called "Barrett's oesophagus". When cells change from what they were born to do, there is an increased risk of cancer. That risk, by the way, is extremely tiny. One rough and ready clue that Barrett's change might have happened is when someone has had heartburn for years and then it suddenly disappears- they are happy, but shouldn't be!
Investigations
Most people who have recurrent reflux end up having an endoscopy. It's not absolutely necessary, but no harm as it can exclude the presence of Barrett's. Strangely, in probably 9 people out of 10 with reflux, the endoscopy is completely normal. This get's to an earlier point, that reflux symptoms are all about acid being in the wrong place, not necessarily about it doing damage.
Most people will have a test done for the stomach bug Helicobacter pylori which about a third of us can have. Nobody knows where it comes from, but we can pick it up in childhood and it just lives in the stomach. In some, it tricks the stomach into producing too much acid, giving rise to ulcers. But, it has nothing to do with reflux!
There are specialized tests to measure the amount of acid that is refluxing ("oesophageal ph" studies). The standard test is to have a very fine, thread-like wire hanging out of your nose for 24 hours while you go about your business trying not to be self-conscious. A newer variation is where a tiny, wireless acid-detector is clipped into your lower oesophagus at endoscopy ("BRAVO" procedure). This allows reflux to be measured for up to 4 days. It then falls off and gets flushed away when you go to the loo. Neither of these tests is needed in the majority of cases; their main role being in cases that symptoms behave oddly or if surgery is being considered.
X-Rays such as a "Barium swallow" don't have any great role in this setting.
Treatment
Life-style & Medications
If you get heart-burn when you eat or drink certain things, you know what to do! If you are a bit overweight, you know what to do! Many people though need acid suppressants.
Tablets like Rennies, Tums, Pepto-Bismol or Gaviscon work by trying to counteract acid that has already been produced- so, closing the stable door after the horse has bolted. One good thing about them though is that they work immediately (though not for long).
Medications such as omeprazole, lansoprazole (so called Proton Pump Inhibitors- "PPI's"), ranitidine (an H2-Receptor Antagonist) etc work by reducing the amount of acid your stomach produces in the first place. Your stomach can still produce enough acid to do its work, but not enough to spillover/reflux. In most countries you can get quarter strength doses of these medications over the counter (which are not great), though in the USA, full strength capsules are freely available.
These medications are almost ideal drugs in that they are very safe, can be taken long-term and the body doesn't get used to them. Of course all drugs can cause side-effects in some people, but, these drugs that have been around for over 30 years and hugely widely used, so a lot is known about them. Still, best practice is to use only if needed and at the lowest effective dose. A rule of thumb, by the way, is that if you get reflux more than twice per week, you should take a medication every day. Not everyone's ideal situation when you're twenty-five or thirty years old, but none of this is about philosophy!
However, the one problem with PPI's etc is that they only work if you take them! That is the flaw with trying to cure a "mechanical" problem with a tablet.
Surgery
Anti-reflux surgery can work very well and is done by key-hole nowadays, but it is best reserved for those in whom medication is not working or who don't want to take more medications. Also, it must be done by a dedicated oesophageal surgeon as if it goes wrong, it can be difficult to fix.
Given how common reflux is, the long-term nature of its treatment and the issues of surgery, many non-invasive, endoscopic techniques have been tried. They work a bit, for a while, but are rarely a good solution. Also, they can't be done if you have an hiatus hernia.
A relatively new technique is to insert a titanium "bracelet" around the lower oesophagus to tighten things up. It seems to work but there are concerns because a plastic version of this was used back in the 1980's with disastrous consequences due to the ring eroding into the gullet.
Finally, some studies have been done on using an implantable "pace-maker" that controls the muscular tone of the the lower oesophagus. It's far to early to know if this really works.
The symptoms
The commonest symptom is burning behind the lower breast-bone ("heartburn"), but a good number of people get atypical symptoms such as the feeling of something stuck in their throat (called "globus"), change in voice, damaged tooth enamel or odd chest pains. What causes these problems is acid being in the wrong place. This acid does not necessarily do any damage (and usually doesn't), but the body senses it and doesn't like it.
For some people the symptoms come on after eating a rich meal, drinking alcohol (especially prosecco/champagne) or having a late meal before going to bed. That's easy, you know what to do, but, many others get symptoms no matter what they eat or do and they keep happening.
Why the reflux?
You need to understand the anatomy of the stomach and gullet (proper name oesophagus) to see why it all happens.
Firstly, the job of the oesophagus is purely to be like a boa-constrictor and squeeze food along from the mouth, down to the stomach. So two important things: (a) the oesophagus is a long, hollow tube of muscle and (b) its lining is not made for dealing with acid.
Secondly, the job of the stomach is to churn food with acid, turning it into a "soup" that can be slowly broken down and absorbed as it makes its way down along the next bit of gut, the small intestine ("small" because it's narrow, it's about 5 metres long). So, the lining of the stomach is made to tolerate acid.
This all means that if the junction between the oesophagus and the stomach doesn't function properly, acid can flow back up- "reflux". So, why might the junction not work properly? Two possible reasons, but, more anatomy first.
The chest is sealed off from the abdomen by a big "canvas" of muscle called the diaphragm. This is a bit of a design problem though, as the oesophagus has to be able to get down to the stomach and the big blood vessels have to be able to get up and down from the heart. To allow all of this "pipe-work", there is a tear-drop shaped space in the middle of the diaphragm called a "hiatus". In many people, this hiatus is slightly too wide. Not a problem in it's own right, but, it does allow maybe an inch or so of the stomach to slide up and down. This can allow acid to leak upwards. On this point and to explain a phrase that you may come across, when part of the body slides out of its proper position it is called a "hernia"- hence all of this is called a "hiatus hernia". It is quite different by the way from hernias elsewhere in the body which can get "stuck" and so need surgery; a hiatus hernia almost never gets stuck.
Not everyone with reflux has a hiatus hernia though. For many people it is another problem. More anatomy, I'm afraid!
As we know the oesophagus is a long tube of muscle and all muscle has "tone". With the oesophagus, the lowest inch or so, just before where it joins with the stomach, has increased tone which keeps it tight shut, only opening when food is coming down. The problem is that in may people this area can relax at the wrong time, when the stomach has started producing all its acid- so called "inappropriate relaxation". Nobody knows why it happens, but it is a problem.
The other thing to throw into the mix is gravity. When you're standing everything drains downwards but go to bed and then your oesophagus, the stomach and its acid contents are all on the same level. You wake up!
The message from all of this is that the key causes of acid reflux are "mechanical" problems; the machinery is not working. No surprise then that when reflux starts to happen it just keeps on going for 7 people out of 10. As to why it should start in the first place, nobody has a clue which doesn't help the level of frustration caused by all of this.
Why do some foods worsen things?
Two things to know to understand the impact that food type has on reflux: (a) if rich foods could go straight through to the small intestine, we would all end up with bad cramps and diarrhoea. The flow needs to be slowed and regulated; (b) the stomach can sense what type of food is there.
When the stomach senses oily foods (pizza, finest olive oil, fish & chips all the same to it!), alcohol, caffeine and chocolate, or if there is nicotine about, it slows down, leaving us with a noxious, acidic soup ready to spill over back up into the oesophagus.
Does reflux cause any long-term problems?
Short answer: for the majority of people, no.
Long answer, exposing the lower oesophagus to acid reflux over many years can cause scarring with narrowing of the gullet leading to problems with swallowing ("dysphagia"). Also, in about 5 people out of every 100 with long-term reflux, the cells lining the lower oesophagus can change to protect themselves from the acid. This is called "Barrett's oesophagus". When cells change from what they were born to do, there is an increased risk of cancer. That risk, by the way, is extremely tiny. One rough and ready clue that Barrett's change might have happened is when someone has had heartburn for years and then it suddenly disappears- they are happy, but shouldn't be!
Investigations
Most people who have recurrent reflux end up having an endoscopy. It's not absolutely necessary, but no harm as it can exclude the presence of Barrett's. Strangely, in probably 9 people out of 10 with reflux, the endoscopy is completely normal. This get's to an earlier point, that reflux symptoms are all about acid being in the wrong place, not necessarily about it doing damage.
Most people will have a test done for the stomach bug Helicobacter pylori which about a third of us can have. Nobody knows where it comes from, but we can pick it up in childhood and it just lives in the stomach. In some, it tricks the stomach into producing too much acid, giving rise to ulcers. But, it has nothing to do with reflux!
There are specialized tests to measure the amount of acid that is refluxing ("oesophageal ph" studies). The standard test is to have a very fine, thread-like wire hanging out of your nose for 24 hours while you go about your business trying not to be self-conscious. A newer variation is where a tiny, wireless acid-detector is clipped into your lower oesophagus at endoscopy ("BRAVO" procedure). This allows reflux to be measured for up to 4 days. It then falls off and gets flushed away when you go to the loo. Neither of these tests is needed in the majority of cases; their main role being in cases that symptoms behave oddly or if surgery is being considered.
X-Rays such as a "Barium swallow" don't have any great role in this setting.
Treatment
Life-style & Medications
If you get heart-burn when you eat or drink certain things, you know what to do! If you are a bit overweight, you know what to do! Many people though need acid suppressants.
Tablets like Rennies, Tums, Pepto-Bismol or Gaviscon work by trying to counteract acid that has already been produced- so, closing the stable door after the horse has bolted. One good thing about them though is that they work immediately (though not for long).
Medications such as omeprazole, lansoprazole (so called Proton Pump Inhibitors- "PPI's"), ranitidine (an H2-Receptor Antagonist) etc work by reducing the amount of acid your stomach produces in the first place. Your stomach can still produce enough acid to do its work, but not enough to spillover/reflux. In most countries you can get quarter strength doses of these medications over the counter (which are not great), though in the USA, full strength capsules are freely available.
These medications are almost ideal drugs in that they are very safe, can be taken long-term and the body doesn't get used to them. Of course all drugs can cause side-effects in some people, but, these drugs that have been around for over 30 years and hugely widely used, so a lot is known about them. Still, best practice is to use only if needed and at the lowest effective dose. A rule of thumb, by the way, is that if you get reflux more than twice per week, you should take a medication every day. Not everyone's ideal situation when you're twenty-five or thirty years old, but none of this is about philosophy!
However, the one problem with PPI's etc is that they only work if you take them! That is the flaw with trying to cure a "mechanical" problem with a tablet.
Surgery
Anti-reflux surgery can work very well and is done by key-hole nowadays, but it is best reserved for those in whom medication is not working or who don't want to take more medications. Also, it must be done by a dedicated oesophageal surgeon as if it goes wrong, it can be difficult to fix.
Given how common reflux is, the long-term nature of its treatment and the issues of surgery, many non-invasive, endoscopic techniques have been tried. They work a bit, for a while, but are rarely a good solution. Also, they can't be done if you have an hiatus hernia.
A relatively new technique is to insert a titanium "bracelet" around the lower oesophagus to tighten things up. It seems to work but there are concerns because a plastic version of this was used back in the 1980's with disastrous consequences due to the ring eroding into the gullet.
Finally, some studies have been done on using an implantable "pace-maker" that controls the muscular tone of the the lower oesophagus. It's far to early to know if this really works.
