Part 1: Is Acid Reflux (aka, GERD) Really About Too Much Acid? Probably Not!

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Doesn’t it seem like everyone struggles with heartburn these days? Whether it’s once in a while or after every meal, many people have a burning sensation in their chest or throat or experience regurgitation of sour liquid into the throat or mouth. Ugh, it’s not even pleasant to describe in writing!

As you are well aware from your own experience or that of a friend or loved one, the remedy for occasional acid reflux is antacids. If heartburn happens more regularly, a person may take an over-the-counter drug or get a prescription for a proton pump inhibitor, both of which are meant to reduce the amount of acid produced by the stomach.

The problem with all three of these remedies is that they stop the action of acid in the stomach, which might make you feel better momentarily, but have negative effects throughout the body. As well, in most cases, they aren’t even solving the real problem, as acid reflux and GERD are often not a result of too much acid in the stomach!

Now, I realize that may be a whole new concept to you, so stick with me and I’ll explain what I mean and how you can truly resolve your heartburn without negatively affecting your health.

What is Acid Reflux?

Acid reflux (or indigestion or heartburn) is a feeling of burning in the chest or throat that happens when the acidic contents of the stomach back up into the esophagus. Acid reflux becomes gastroesophageal reflux disease (GERD) when it happens frequently and leads to other symptoms such as difficulty swallowing, coughing, wheezing, and chest pain, especially when lying down. (I will use the terms interchangeably from here on to describe the symptoms that are felt.)

In acid reflux and GERD, the mechanisms meant to protect the esophagus fail and the epithelial cells of the esophagus and stomach are exposed to the acidic digestive juices, which leads to the classic burning feeling. There are two forms of reflux disease:

  • Erosive GERD: acid reflux which causes erosion of the esophagus, esophagitis (esophageal inflammation), ulcers, scarring and/or severe narrowing (i.e., stricturing) of the esophagus. Long-term erosive GERD leads to Barrett’s esophagus for 5 – 15% of people who have it (especially white men, for unknown reasons). Barrett’s esophagus is a precancerous condition in which the esophageal cells closest to the stomach turn into abnormal columnar cells (more on these in a minute) and can turn cancerous over time.
  • Non-Erosive Reflux Disease (sometimes called NERD): acid reflux not characterized by esophageal erosion

Interestingly, research has shown that people with NERD sometimes experience more symptoms typical of acid reflux than those with erosive GERD! So, unfortunately, the only way to determine the severity and impact of acid reflux on the esophagus is via endoscopy.

Now that we’ve covered what it is, let’s talk about what is actually happening…

The lower esophageal sphincter (LES) separates the esophagus and the stomach. Normally, the LES is closed (i.e., contracted), except when you swallow. The action of swallowing triggers the muscles of the esophagus to push the bolus of food down. (It’s not a passive action, which is why you can swallow even when you are upside down.) When the bolus gets to the end of the esophagus, the sphincter relaxes and allows the food to enter the stomach. In order for the burning sensation to occur, the esophageal sphincter must relax or open such that the contents of the stomach can flow backward into the esophagus.

The problem here is not that the stomach produces acid (because it’s supposed to do that). Rather, the problem is that the acid is getting out of the stomach and into the esophagus.

As well, there is another condition that feels like acid reflux, but is related to the stomach and not the esophagus!

The stomach is lined with columnar cells, which are special cells that are taller than they are wide and, therefore, are protective. After all, our organs are primarily made of protein and our stomach is the place that digestion of dietary proteins occurs, so a protection is a necessary thing! In addition to offering protection due to their size, columnar cells are also excellent at secreting and absorbing, both super important functions in the digestive system. Among other things, the stomach’s columnar cells secrete mucus which provides the stomach cells an extra layer of protection from the acidic digestive juices.

If this mucous lining breaks down, the stomach lining is exposed to the acid and digestive enzymes and can become inflamed, which is known as gastritis. As with GERD, gastritis can be erosive or non-erosive. In erosive gastritis, the erosions can be shallow or deep, with deep erosions being classified as ulcers.

Unfortunately, there is a cumulative effect with gastritis because inflamed cells produce less mucus (meaning that the protection lessens even more) and less digestive enzymes (which is also a problem, as you’ll see shortly).

Why are Conventional Acid Reflux Treatments a Bad Idea?

As mentioned before, the commonly accepted remedy for occasional acid reflux is antacids, which contain substances to neutralize stomach acid. A step above this are over-the-counter H2 receptor blockers (like famotidine or ranitidine) which reduce acid production. And in more severe cases where heartburn happens “all the time”, a doctor is likely to prescribe a proton pump inhibitor (like lansoprazole or omeprazole) to block acid production in the stomach.

The problem with all of these treatments is that they stop the stomach from doing what it needs to do to digest food (i.e., produce acid) and keep us healthy without addressing the cause of the problem. For example, if the problem is in the esophagus, why is acid getting into the esophagus in the first place? And if the problem is in the stomach, why is there not enough mucus to protect the stomach?

The only scenario for which these medications solve the root cause of a problem is if the stomach actually is producing too much acid. And the only way to know if this is the case is to do a pH test within the stomach. Unfortunately, most doctors diagnose acid reflux based on symptoms and prescribe a PPI without considering the cause of the problem or, even worse, the impact of the intervention!

You see, when used continuously, interventions that stop the stomach from producing acid and digesting food causes problems throughout the body, including:

  • Increased risk of pathogenic infection due to:
    • Allowing bacteria, yeast and other pathogens to grow in the digestive tract that would normally be killed by the acid
    • Decreased phagocytic activity by neutrophils, a specific kind of white blood cell that devours invaders through phagocytosis
  • Ineffective digestion of protein which may prevent it from being absorbed in the intestine and can lead to protein malnutrition
  • Reduced ability of the digestive system to absorb certain vitamins and minerals, including vitamin B12calcium, iron, copper and folic acid, which can lead to complications associated with deficiency such as increased risk of hip fractures
  • Inadequate signaling to:
    • The pancreas to release digestive enzymes into the small intestine further impairing digestive ability
    • The lower esophageal sphincter to stay tightly closed (See how this can become a dangerous spiral?! You take a PPI to stop acid from getting into the esophagus, but the acid is needed to help the sphincter stay tightly closed!)
  • Increased production of gastrin, the hormone that tells the stomach to secrete stomach acid (although research to date has not shown any negative outcome if increased gastrin levels)

Important note: Even though the above are significant side effects to be considered, if you are currently taking a PPI, do not simply stop taking it, as you may experience a rebound effect. Rather, talk with you healthcare provider about how to effectively wean yourself off of them and address the underlying cause.

What Causes Acid Reflux?

Because acid reflux describes the general symptom of a burning sensation, the causes are numerous and widely varied, potentially originating with anything from your emotions to your genetics. The possible causes are listed here in rough order of commonality:

  • Inefficient or inadequate digestion due to:
    • Insufficient chewing of food or eating a very large meal… The food stays in the stomach longer so it can be sufficiently broken down to enter the small intestine, which increases the likelihood of acid getting into the esophagus.
    • Insufficient production of stomach acid… This is not a typo. It seems like it’s too much when the problem it really too little acid. The result is that the food stays in the stomach for a long time and, again, the chance of acid refluxing into the esophagus is greater.
    • Insufficient production of pancreatic digestive enzymes, which work with the acid to digest protein.
    • Inadequate vagus nerve stimulation
  • Gastroparesis or delayed stomach emptying caused by something on this list, oxidative stress or neurotransmitter deficiency
  • Food sensitivity / intolerancedairy and soy are common ones, but it could be any food.
  • Eating foods that loosen the sphincter between the esophagus and the stomach, which makes the acid more likely to reflux. These include alcohol, citrus fruits, tomatoes, chocolate, caffeine, coffee, mint, spicy/hot peppers and ground pepper (black, red, white and green).
  • Medications and drugs, such as:
    • NSAIDs and anti-inflammatories like aspirin and ibuprofen, which are known to damage the lining of the stomach and the intestine making it more sensitive to the acid
    • Antidepressants, antibiotics, nitroglycerin, and anxiety, hypertension or osteoporosis medications, which have a known side effect of causing acid reflux
    • Cocaine
  • Constipation
  • Emotional or physical stress
  • Hiatal hernia
  • Infections by a microscopic pathogen, such as:
    • Helicobacter pylori infection… although this bacteria can cause gastritis, it is worth noting that lots of people have this microbe living in their stomach and experience no problems from it what-so-ever. It is estimated that only 10 – 15% of people infected by H. pylori develop symptoms and some researchers are starting to suggest that this bacteria may be helpful to some.
    • Bacteria (other than H. pylori), parasites, fungi (which includes yeast) or viruses (See my post on dysbiosis for more on this)
  • Autoimmune conditions such as autoimmune metaplastic atrophic gastritis (aka, autoimmune gastritis or AMAG) and Crohn’s disease
  • Zinc or chloride deficiency
  • Sarcoidosis, which triggers systemic inflammation
  • Overproduction of stomach acid
  • Reflux of bile from the small intestine into the stomach

So, let’s play out a scenario to help you understand how the above interact with each other and why taking a proton pump inhibitor doesn’t help. To explain this example problem, here’s a little biochemistry:

Pepsinogen is a zymogen (an enzyme precursor) that is secreted by the stomach. When pepsinogen interacts with hydrochloric acid, it becomes pepsin, the stomach enzyme responsible for breaking proteins into polypeptides. Once the contents of the stomach have been broken down sufficiently, the chyme (or mass of semi-digested food and enzymes) is released into the small intestine for further digestion and nutrient absorption.

Now, let’s say that you don’t produce enough pepsinogen. The hydrochloric acid is still secreted, but has very little to interact with, so pepsin is generated in small amounts and protein isn’t digested efficiently. As a result, the food stays in the stomach longer waiting for the inadequate enzymes to slowly do their work. The longer the food sits in the stomach, the more likely it is to be fermented by the small numbers of bacteria that are normally found there (or large numbers, if the acid has been suppressed long enough that bacterial overgrowth has occurred). This fermentation will cause burping, which requires the lower esophageal sphincter to relax and may allow the contents to reflux into the esophagus. Add to this the extra large meals that many people consume and you have a time bomb waiting to go off.

As you can see, our primary problem here is inadequate digestive enzymes (although meal size and inadequate chewing might also be contributing). If you add a proton pump inhibitor to this, you now have inadequate digestive enzymes and inadequate hydrochloric acid. It’s like having a bicycle with one flat tire and deciding to slash the other tire in an effort to solve the problem! It makes no sense and doesn’t actually fix anything!

If we took each of the causes in the list above, we could construct similar scenarios where we show that we have a problem and introduce another problem by stopping acid production. The only time we wouldn’t be introducing a problem is if the stomach actually is producing too much acid, and most gut health experts agree this scenario accounts for a small percentage of the people experiencing acid reflux, heartburn, indigestion and/or GERD.

Obviously, this doesn’t change that the acid burns and you want relief. However, knowing that the problem likely isn’t too much acid should change how we approach resolution.

Now check out part 2 in which I give you ideas on how to alleviate your symptoms and address the root cause of the problem.

 

Sources:
— Allen S. Gastrointestinal Health from a Functional Medicine Perspective. Webinar held on February 11, 2015.
— Konoske T. Gut Health: Part 1 (GERD, SIBO, IBS, IBD). Webinar held on January 11, 2016.
— Kusano M, Hosaka H, Kawamura O, et al. More severe upper gastrointestinal symptoms associated with non-erosive reflux disease than with erosive gastroesophageal reflux disease during maintenance proton pump inhibitor therapy. Journal of Gastroenterology. 2015;50(3):298-304.
— Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012.
— Mayo Clinic. GERD Tests and Diagnosis. In Diseases and Conditions. July 31, 2014. Accessed on April 4, 2016.
— The National Institute of Diabetes and Digestive and Kidney Diseases. Gastritis. In Health Information. July 2015. Accessed on March 30, 2016.

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