Acid Reflux and GERD

Posted: February 7, 2011               Share

Almost everyone has experienced heartburn, acid indigestion, or acid reflux at some point in their lives-a bit of food comes back up causing pain and a burning sensation in the throat, chest, or mouth. Reflux happens because a ringlike muscle at the base of the esophagus called the lower esophageal sphincter (LES), opens improperly, and the burning sensation happens because stomach acids come up with the food. Occasional reflux is no big deal, but chronic reflux that happens more than twice a week is called gastroesophageal reflux disease, or GERD, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). GERD can eventually lead to esophageal ulcers (bleeding sores), esophageal stricture from the formation of scar tissue that replaces normal tissue after acid damage, and to Barrett's esophagus (replacement of normal esophageal tissue with tissue that more closely resembles that of the intestine), and esophageal cancer.

Causes of reflux are unclear; normally, the LES will relax to let out excess air that is swallowed during eating (burping). But anatomical variations such as hiatal hernia, pregnancy, and obesity are thought to cause mechanical stress contributing to abnormal opening of the LES. Reflux may also be caused by pathological mechanical obstruction. A previous peptic ulcer may have formed scar tissue that disrupts normal stomach emptying, or the pylorus (the part of the stomach next to the pyloric sphincter) can sometimes grow abnormally large and thick and interfere with normal stomach emptying. When the stomach cannot empty itself properly, the contents of a meal remain in the stomach maintaining high relative pressure causing greater chance of reflux through the LES when the stomach contracts to move food into the duodenum (the upper portion of the small intestine). Large meals will also have this effect on the stomach and LES.

Foods such as chocolate, fats, and caffeine relax the LES exacerbating reflux. Alcohol has the dual effect of not only relaxing LES, but also increasing acidity of stomach contents making reflux more frequent and damaging.

Stomach Acid: Too Much or Too Little?
Perhaps the biggest myth associated with acid reflux is that it is caused by an excessive amount of hydrochloric acid (HCl) in the stomach. This is rarely the case. Rather, the amount of acid seems relatively in excess when it refluxes into the esophagus and causes pain and tissue damage. In fact, the root problem is much more likely to be a deficient amount of stomach acid, called hypochlorhydria or achlorhydria. What makes matters even more confusing is that either condition can cause reflux and GERD.

The right amount of acid is essential to good health because it is necessary to digest protein, carbohydrates, and fats, and keeps ingested bacteria and fungi in check.¹ It is also necessary to absorb micronutrients, especially calcium, magnesium, zinc, copper, iron, selenium, and boron as well as vitamin B₁₂. Symptoms of low stomach acid include bad breath (from out-of-control bacterial or fungal overgrowth), belching, bloating, constipation, distension; there may be fatigue due to malabsorption of nutrients. Chronically deficient stomach acid sets the stage for the development of food sensitivities or allergies because undigested food particles pass into the small intestine where they go unrecognized as nutrients. Unrecognized food particles may be mistaken for viral or bacterial antigens and set off an immune response that results in bowel inflammation and/or diarrhea whenever one is exposed to the same type of food particles.¹

Maintaining a Balance
The stomach is lined with two types of cells: parietal cells that secrete HCl, and epithelial cells that secrete mucus, which makes up the gastric mucosa, or lining, that is highly resistant to damage from acid in a normal, healthy stomach. This is not to say damage never occurs, but rather that when damage does occur, a healthy stomach can repair itself swiftly and with little or no disruption in normal functioning.² The epithelial cells of the stomach renew themselves every 2 to 4 days in normal adults.³ This process is called restitution. With damage to the mucosa, the stomach lining becomes inflamed (gastritits), and inflammation causes increased permeability of the mucosa by acid. Acid leaks or "back diffuses" through the mucosal layer in between cells and destroys them. The movement of acid from the inside of the stomach, through the mucosa into the cell interspaces also reduces the acidity of the stomach contents.

Too Little Acid: Hypochlorhydria
Simply put, inflammation induces hypochlorhydria in the stomach by damaging the mucosa. The mucosa can become inflamed in several ways including:

1. chronic use of non-steroidal anti-inflammatory drugs (NSAIDs)
2. too much alcohol
3. bile salts
4. bacterial or viral infections (especially H. pylori, the ulcer-causing bacteria)
5. food allergies

NSAIDs such as aspirin, ibuprofen, naproxen, and Celebrex damage the gastric mucosa by inhibiting the action of prostaglandins, which are hormone-like substances that have a protective effect on the gastric mucosa.² Prostaglandins protect the stomach by (1) inhibiting gastric acid secretion, (2) stimulating the secretion of bicarbonate and mucus, (3) reducing permeability and reducing acid back-diffusion into stomach epithelial cells, and (4) by acting as vasodilators increasing blood flow to cells and facilitating restitution. Some types of NSAIDs work by selectively inhibiting certain types of prostaglandins, and are substantially less harmful (Celebrex), but with chronic use, they still can cause significant injury.² Repeated exposure to inflammatory agents slows restitution and damages and prematurely ages the stomach. Parietal and epithelial cells are replaced with scar tissue decreasing the overall ability of the stomach to not only protect itself from HCl, but also reduces its ability to produce sufficient HCl for digestion resulting in hypochlorhydria and malabsorption syndromes.

Too Little Acid Causes Acid Reflux
The pyloric sphincter (the ringlike muscle at the lower end of the stomach that regulates flow of stomach contents into the small intestine) is sensitive to acid, and only relaxes when the acidity of the stomach is correct (eg, at pH 2-4).⁴ When there is insufficient gastric acid, the pyloric sphincter doesn't open properly, the volume of stomach contents and stomach pressure build causing greater chance of reflux when the stomach contracts to move food into the duodenum. Even though the food isn't acidic enough to open the pyloric sphincter, it is still acidic enough to cause discomfort and burning to the esophagus.⁴

Too Much Acid: Hyperchlorhydria
Hypersecretion of gastric acid does sometimes occur. In people who have had intracranial injury, operations, or tumors ulcers and/or reflux can be caused by increased intracranial pressure.⁵ The increased pressure in the brain can press on the vagus nerve, which stems from the brain and connects to and controls most internal organs. When the vagus nerve is overstimulated, it can overstimulate the stomach resulting in hypersecretion of HCl. Ulcers that result from this are called Cushing ulcers.

Too much stomach acid can also be caused by gastrin-secreting tumors, called gastrinomas, that occur in Zollinger-Ellison syndrome.⁵ The excess gastrin causes hyperchlorhydria, reflux and diarrhea. Another rare disorder characterized by high blood gastrin levels and gastrinomas is called multiple endocrine neoplasia type 1 (MEN 1). It is characterized by hyperparathyroidism, multiple endocrine tumors, including gastrinomas.

Conventional Treatment
The standard treatment is to prescribe medicines that create a more alkaline environment to promote healing of the esophagus. The western medical repertoire for treating GERD includes:

• Antacids (eg, Maalox, Rolaids, TUMs), which neutralize stomach acid and minimize damage from acid to esophageal tissues. If symptoms are completely relieved by antacids, then inflammation is probably due to excessive acid production.⁶
• Antihistamine Blockers (eg, Pepcid AC, Tagamet, Zantac), which decrease stomach acid secretion; certain of these drugs unfortunately have also been shown to inhibit opening of the pyloric sphincter, which exacerbates GERD. ⁷
• Proton Pump Inhibitors (eg, Aciphex Prevacid, Prilosec, Protonix, Nexium) also decrease the production of stomach acid, but are considered much stronger inhibitors than antihistamine blockers. Side effects include bone loss and vitamin B₁₂ deficiency; less acid means less calcium gets absorbed from the diet, which is thought to contribute to the increased incidence of hip fracture, especially in the elderly.⁸ Additionally, stopping PPIs may cause rebound reflux, meaning reflux symptoms get worse than they were before starting the PPI. The rebound is thought to be a result of the overproduction of the acid-stimulating hormone gastrin, the body's natural response to the PPI suppressing acid secretion. When PPIs are stopped after long-term use, the excess gastrin still in the blood stream causes the stomach to secret too much HCl, which can lead to more intense reflux and diarrhea in the short term. ⁹ If you have GERD and you have been on PPIs long term and want to get off, you will probably have to taper off and/or switch medications. You could try a prokinetic (see below) and use antacids to deal with the rebound reflux until production of gastrin normalizes again, and normal levels of stomach acid are restored.
• Prokinetics (eg, Reglan) promote gastric motility (faster emptying of the stomach), relax the pyloric sphincter, and stimulate the secretion of digestive enzymes from the pancreas. These drugs do not seem to interfere with acid production and come closer to treating the root cause of hypochlorhydria-induced reflux in some people. However, these drugs may adversely affect the central nervous system, causing restlessness, drowsiness, insomnia, and in some rare cases, tremors.
• Surgery to repair hiatial hernia and/or strengthen the LES can sometimes be helpful, according to the NIDDK. As with any surgery, the long term effects of these procedures are unknown, and there can be no guarantees that it will eliminate reflux.

The problem with most of the standard medications is that they are overused. Most PPIs are only supposed to be taken for 1 or 2 weeks, but many people take them "as needed" which can quickly become a daily occurrence.

The Chinese Medical Perspective
Reflux, or any kind of backward-moving energy such as vomiting, coughing, or sneezing is known as counterflow qi. It just means the usual flow of energy has been disrupted and needs to be restored to its normal pattern of downward movement.

The main cause is thought to be stagnant Liver qi, which results from unfulfilled desires, or unexpressed anger or frustration. Prolonged emotional upset causes the Liver qi to become pent up and therefore in excess, the theory goes, and pent-up qi must eventually overflow somewhere. That somewhere is the path of least resistance, a path often leading to the Stomach. Thus, the Liver "overacts" on the Stomach causing digestive disturbances. When the Stomach is the recipient, it can counterflow upward resulting in acid reflux or vomiting.

These old theories are relevant today when you consider that stress causes overstimulation of the sympathetic nervous system, responsible for "fight-or-flight" body functions, and under-stimulation of the parasympathetic nervous system, responsible for "rest-and-digest" body functions. When the body is under chronic stress, digestion and absorption of nutrients suffer because the stomach is not stimulated to produce enough gastric acid to digest food, nor is it stimulated into peristaltic action to help mechanically digest and move food into the small intestine.

Chronic stress that causes long-term Liver qi accumulation along with accumulation of excess qi in the Stomach lead to buildup of heat that manifests as burning pain and sometimes counterflow qi, or reflux. When heat is severe, all the ancient Chinese medical references say that it may "move frenetically outside its channels", which is exactly what is happening when HCl seeps back in between stomach cells contributing to bleeding ulcers in the stomach, and when it refluxes into the esophagus burning it and causing bleeding ulcers there.

There are other patterns and theories about reflux and GERD from an ancient Chinese perspective, but they are too numerous and complex to explain adequately here.

Natural Approaches
There is plenty you can do if you have reflux and want to avoid the side effects of pharmaceutical medications.

More Acid: The problem with this approach is that often symptoms of GERD will be exacerbated in the short run.¹ The key to success is to change the diet (see under Diet and Lifestyle Adjustments, below) and to take acid supplements with food to ensure that the pyloric sphincter opens properly. The prokinetic pharmaceuticals can be useful for this approach as well.

• Apple Cider Vinegar: This is a preventive remedy that many people swear by. Take 1 - 2 tsp in 8 oz of water with meals to boost stomach acid content, facilitate digestion, and relax that pyloric sphincter.
• Vitamin C Crystals: Like apple cider vinegar, this is a preventive remedy for people who have problems with yeast who don't want to use vinegar. Dissolve 1 tsp of vitamin C crystals in 8 oz of water or juice and take with meals. If it's too sour, or causes burning pain, add a pinch of baking soda to the mix.
• Betaine Hydrochloride: This is available in capsules by prescription only and should be taken with food. The dose is adjusted based on the response. Some people start with one or two capsules and work up to 4 or 5 depending on the size of a meal and on the response to treatment. The goal is to correct the diet, and eliminate gastritis-causing factors so that the stomach can produce acid normally.¹
• Turmeric: The active ingredient in turmeric, curcumin, is known to increase gastric acid secretion¹⁰ and may be a histamine blocker.¹¹ According to Chinese medical tradition, it relieves any type of pain below the diaphragm caused by Liver qi stagnation, and it has been a mainstay to treat stomach irritation in the ayurvedic tradition for thousands of years as well. In one study, 20 patients with bleeding ulcers were treated with tea made from turmeric and other Chinese herbs with good results.¹⁰

Less Acid: These remedies will help neutralize acid giving injured, inflammed gastric tissue time to heal.

• Baking Soda: For temporary relief of the raw feeling in your throat after a bout of reflux, dissolve 1 tsp of baking soda in 8 oz of water and drink it. This will also neutralize the acid in your stomach and prolong digestion, so use this remedy sparingly. Try this remedy when trying to wean yourself from PPIs.
• Goldenseal (aka Coptis): This very bitter and alkaline herb will counteract excess acid. It also has antibiotic properties and may therefore be useful to treat H. pylori infection. It is most useful as a topical treatment, so it is appropriate to use it to treat ulcers in the digestive tract because it will come in direct contact wiht the affected areas. Some sources say it inhibits gastric acid secretion.¹² Use capsules or as tea; the tanins in tinctures can cause gastritis; do not use if pregnant or nursing.¹³
• Licorice Root: Licorice root inhibits gastric acid secretion, according to one source,¹⁴ but others say protects by fortifying the stomach's protective mucous coating therby promoting the healing of ulcers.¹⁵
It is known for relieving stomach pain due to gastritis and ulcers.

Harmonizing Acidity and Alkalinity: These remedies are aimed more at harmonizing the stomach so that the correct amount of acid is produced and the gastric mucosa is supported. Energetically they support the harmonious opening and closing of the LES and the pyloric sphincter as well as the timeliness of stomach peristalsis or contraction.

• Acupuncture: This can help redirect stomach energy downward and rebalance the pH of the stomach to optimal levels for digestion. It will help regardless of whether your problem is too little acid, or too much. It also helps relieve stress, and stimulates the parasympathetic nervous system, which regulates digestion and absorption. One study found that adding acupuncture to a treatment regimen was more effective than doubling the dose of PPIs in patients who are non-responsive to an initial course of treatment.¹⁶ Acupuncture was also effective in treating critically ill patients with delayed gastric emptying to reduce reflux and improve the efficacy of parenteral feeding.¹⁷ Acupuncture was as effective as omeprazole (a prokinetic medication) in a study of 60 people in treating symptoms of reflux.¹⁸ In addition, a study of cats showed that acupuncture can lower incidence of transient LES relaxation.¹⁹
• Ginger: fresh, powdered, in capsules, or as tea, ginger is known to help soothe nausea, but studies have also shown that it stimulates production of gastric mucosa as well as increases intestinal motility; thus it will help heal gastritis or ulcers as well as facilitate timely emptying of the stomach.²⁰
• Cinnamon: Use 2-3 g of cinnamon stick to make a tea. Cinnamon has a mild stimulating effect on the gastrointestinal tract, increases saliva secretion as well as gastric acid secretion, thus enhancing digestion.²¹ Cinnamon is also known to relieve intestinal gas and to block the creation of chemicals that cause inflammation.²² Be careful not to overdo it, too much cinnamon can exacerbate reflux. Several prepared bagged and loose teas include cinnamon as well as ginger in them, including most chai teas.

Diet and Lifestyle Adjustments Most of these suggestions come from Dr. Andrew Saul's site, DoctorYourself.com:

• Make your midday meal the largest, and don't eat after 5 pm.
• Eat only easy-to-digest foods, such as rice, steamed veggies, sprouted seeds and grains, well cooked beans, aged cheeses, yogurt, and cottage cheese.
• Get a juicer and drink lots of vegetable juices; these are naturally alkaline, which should neutralize excess acid from PPI overuse and soothe burned throat tissues.
• Use digestive enzymes. Get them in fresh pineapple, dried or fresh papaya, dried figs, or in capsules from the local health food store to help reduce reflux due to hypochlorhydria.
• Avoid citrus fruits and tomatoes, chocolate, caffeinated beverages, fatty or deep-fried foods, garlic, onions, spicy foods.
• Drink cabbage juice; this helps heal sores from acid damage to the esophagus and helps heal ulcers. Dr. Garnett Cheney, MD, tested a regimen of 4 glasses of cabbage juice per day on 13 patients and found that their ulcers healed in about a quarter of the time it took patients who did not use this regimen.
• Let gravity be your friend. Raise the head of your bed by putting blocks under the bed legs at the head of the bed; don't try to just use pillows to prop up your head, according to WebMD, that will create an angle that only incrases pressure on your stomach making your heartburn worse.
• Stop smoking: nicotine weakens the LES making symptoms of reflux worse, according to WebMD.

Seeking Help from an MD
If your symptoms don't improve after trying natural home remedies or a short course (two weeks or less) of over-the-counter antacids, PPIs, or antihistamines, see your doctor. According to the Merck Manual, patients who do not improve with drug therapy should undergo endoscopy with biopsy to check for mucosal changes that occur in Barrett's esophagus and to check out esophageal peristalsis to see if it's normal. Some experts say the causes of reflux should be diagnosed with endoscopy to exclude the possibility of cancer and that all stomach ulcers should be biopsied.⁵ In addition, patients whose endoscopy findings are normal should also undergo a 24-hr pH test to check for hypochlorhydria or hyperchlorhydria. If pH tests show hypochlorhydira, blood tests should be run for H. pylori immunoglobulins and for antiparietal cell antibodies to rule out infection or autoimmune conditions, and blood gastrin levels should also be checked.²³

References

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