GERD (Heartburn), Causes, Treatment Issues, Supplements, and Relief

GERD (Heartburn), Causes, Treatment Issues, Supplements, and Relief

Fix Your Gut Podcast on GERD

The Causes, What Your Doctor Does Not Tell You, and How to Find Relief

Increased Gastric Pressure and Heartburn/GERD (gastroesophageal reflux disease)

Heartburn (GERD) is mainly caused by too much intra-abdominal pressure on the stomach from excessive gas production from dysbiosis, causing consistant reflux.1 Excessive intra-abdominal pressure causes stomach contents to push through a closed LES and up through the esophagus where the UES (upper esophageal sphincter) stops the contents and sent they are sent back down into the stomach. The average person refluxes into their esophagus many times throughout the day, and their esophagus is able to clear it. However, when reflux frequency is increased or different reflux contents other than acid and pepsin occur, GERD develops. Increased intra-abdominal pressure can be caused by:

  1. Small intestinal dysbiosis increasing intra-abdominal pressure moving the stomach upward and weakening the lower esophageal sphincter.2
  2. Excess opportunistic H. pylori in the stomach producing excessive gas causing stomach pressure to rise, therefore weakening the LES.3
  3. Standard American diet.4
  4. Ingestion of laboratory genetically modified food.5
  5. Tight fitting clothing (belts mainly) putting excessive pressure on the intestinal tract forces the stomach upward and increases gastric pressure.6
  6. Having incorrect posture which leads to more pressure being put on the stomach by the spine.7
  7. Weakened lower esophageal sphincter due to increased pressure causing more reflux to be forced up through the esophagus.8
  8. Lack of digestive enzymes and stomach acid that causes poor digestion of food which can lead to increased fermentation and gas buildup.9
  9. Candida dysbiosis causing excessive fermentation and gas production putting more pressure on the stomach weakening the LES.10
  10. Constipation that leads to an increase of toxins, gas, fermentation, and microorganisms in the digestive tract, resulting to increased intra-abdominal pressure and weakening the LES. 11
  11. Lack of chloride in the diet which can lead to a decrease in stomach acid production leading to increased gas production in the stomach.12
  12. Poorly functional gallbladder, liver, or pancreas that can lead to either digestive enzyme, bile production issues, and dysbiosis.13
  13. Having a hiatal hernia. 14
  14. Improper defecation posture.15
  15. Suffering from parasitical dysbiosis.16

To correctly treat heartburn you have to choose which above cause is creating your suffering. Some problems may overlap so tackle each problem accordingly.

What is GERD?

Gastroesophageal reflux disease is a condition in which mucosal damage is done to the esophagus, from chronic stomach acid, pepsin, bile, or endotoxins, being trapped between the stomach and the upper esophageal sphincter. Persistent “trapping” of reflux gives you the characteristic feeling of heartburn. The esophagus has antireflux defense mechanisms in place to help protect itself from reflux that occurs throughout the day. When we reflux contents from our stomach, attach itself to the esophagus. One of the defense mechanisms is our esophagus ability to clear the reflux. When we swallow, we swallow a mixture of saliva and salivary bicarbonate to help normalize the pH of the esophagus and inactivate both acid and pepsin. If we reflux into the oral cavity, less saliva and salivary bicarbonate are produced and what is produced is used within our oral cavity to protect the oral mucosa, which is why people with severe reflux have dry mouth. Also, we have cells in our esophageal lining that produce carbonic anhydrase which forms bicarbonate to help further buffer refluxed contents as well. Cells that produce the carbonic anhydrase are found in the basal layer of the esophagus (one of the outermost layers), which is easily damaged by dysbiosis and bile reflux. Having GERD can cause acute and permanent injury to the esophagus, including esophagitis, reduction or GERD defensive mechanisms, esophageal microbiome changes, strictures, or even cancer from chronic inflammation if left untreated.

Someone with GERD usually suffers from a multitude of symptoms including a sore throat, chest pain, gastritis, nausea, and dysphagia (trouble swallowing). If your upper esophageal sphincter is also weakened you can also have the following symptoms breathing issues, increased salivation, dry mouth, facial flushing, stomach chyme regurgitation, vomiting, poor oral health, sleep apnea, trouble sleeping, sinus issues, tinnitus, coughing, and hoarseness. If the GERD is left untreated, it can cause a potentially reversible condition called Barrett’s esophagus where the epithelial lining of the esophagus turns into squamous or intestinal mucosal epithelium which crates a higher risk of developing esophageal cancer.

Acknowledgment of symptoms by a doctor usually makes diagnosis of GERD. However, an endoscopy can be done to get an idea of how damaged the esophagus is and the general function of the LES and stomach. An endoscopy should only be performed when needed because of the associated risks of the procedure. During an endoscopy, a flexible wire with a camera at the end is swallowed, and the camera takes pictures down the esophagus and into the stomach. One of the best tests used in the diagnosing of GERD is an esophageal PH monitoring test. This test is sometimes performed in the hospital for at least twenty-four hours, and during this test, a flexible catheter with a PH monitor on the end is placed through the nose down into the esophagus. It can be uncomfortable to have a tube put down your nose and into your throat, but it can be useful in the diagnosis to determine if you are suffering from reflux.17

Endoscope

The camera of a flexible medical endoscope used for exploration of the upper gastroenteric tract (gastroscopy) the lower enteric tract (proctoscopy, colonoscopy, sigmoidoscopy) and the airways (bronchoscopy). Also for taking biopsies, performing surgery and removing foreign bodies in human procedures.

Conventional Medicine Failed Treatments for GERD and The Average GERD “Cycle”

GERD Standard Treatment

Conventional medicine attempts to treat GERD with acid-reducing medications, and if they fail surgery. Antacids like Tums neutralize stomach acid, making your stomach contents more akaline.. Acid-reducing medications like H2 antagonists or proton pump inhibitors limit the stomach’s production of stomach acid. In theory, this sounds like a great idea for someone who has GERD. If you limit the amount of stomach acid that irritates the esophagus refluxed stomach, a person with GERD should find much-needed relief. However, for most people, the relief is short-lived.18

Antacids – Examples: Tums, Maalox, Gaviscon, milk of magnesia, baking soda – Antacids are drugs that neutralize stomach acid or raise pH levels in the stomach. Antacids are usually free of side effects for most people if they are taken short term. Magnesium hydroxide is one of the safest antacids most people can use, but too much may cause diarrhea. Sodium bicarbonate is another somewhat safe antacid, but it should people with extremely high blood pressure or have a sensitivity to sodium. Sodium bicarbonate can rarely cause bloating and stomach distension (from gas production when the sodium bicarbonate which is alkaline mixes with acidic stomach contents, forming carbon dioxide) and should be mixed well with water and left to settle a few minutes before consumption. I do not recommend the use of calcium carbonate as an antacid. Excess calcium may calcify the arteries if your magnesium storage’s are depleted and are suffering for arterial inflammation and it causes alkalosis (milk-alkali syndrome) with long-term use, which is a serious medical condition. Aluminum is the worst antacid anyone can take since aluminum is neurotoxic and constipates. People with limited kidney function should limit the use of all antacids.

H2 antagonist – Examples: Pepcid AC, Zantac – H2 antagonists are the safest of the stomach acid reducing medications because they only last for about six hours and work by lowering histamine levels in the stomach which lowers stomach acid production. H2 Antagonists can still cause the same problems of lowered levels of stomach acid like PPI’s if taken for a long period of time, even if they have a smaller side effect profile.19

Proton pump inhibitors – Examples: Prilosec, Prevacid – PPI’s might be safe for occasional use (no more than two weeks, lowest dose to achieve relief), when needed (severe gastritis, Zolliger-Ellison syndrome, stomach perforation, ulceration). If you take a PPI longer than a month, then some extra issues might develop from the lack of stomach acid. Patient’s who take PPI’s long-term start to have a whole host of problems including B12 deficiency,20 bone fractures,21 Increased risk of C. diff Infection,22 magnesium deficiency,23 food allergies,24 and SIBO.25 These drugs inhibit the hydrogen/potassium ATPase enzyme system in the gastric cells that secrete stomach acid. These drugs were developed because they last longer that H2 antagonists and usually block acid for one to two days.26

The problem with acid-reducing medications is once you take them long term; the medication does not correct any of the above problems that were the cause of GERD in the first place. By taking a PPI long-term; all the medication is doing is “masking” the symptoms, instead of tackling the original cause of the disease, which there are many. Taking a PPI for a long time leads to the average person reducing the intrinsic factor of the stomach (becoming deficient in B12), further weakening of the LES, developing a magnesium deficiency, developing food allergies from improper food digestion, and even developing or worsening SIBO from the lack of stomach acid which reduces bacterial colonization from food ingestion. The further in reduction of stomach acid from the medicine causes a whole host of problems that the person did not originally have, and since the cause of their GERD has not been dealt with, the person sometimes becomes dependent on using the PPI for the rest of their life.

This “masking” of the symptoms also explains the worsening GERD attacks one has after discontinuing the PPI. The body tries to up-regulate stomach acid to take care of the original issues that started because of PPI medication being taken for so long (dysbiosis, constipation, hiatal hernia, slow gastric emptying, weakened LES). The up-regulation of stomach acid causes worse GERD symptoms than one previously had, because of further increased abdominal pressure and dysbiosis causing more frequent reflux events. The average person goes back on their PPI and the cycle continues until the doctor recommends a useless surgery for relief, Nissen fundoplication.27

Nissen Fundoplication

A Nissen fundoplication is a generally useless and harmful laparoscopic surgery for people suffering from GERD. When a person has the Nissen procedure performed they have the top part of the stomach (gastric fundus) stapled around the LES or the lower part of the esophagus so that it is strengthened and reflux into the esophagus is blocked. The first Nissen was performed by Dr. Rudolph Nissen in 1955.28 Like other conventional GERD treatments, this seems like a great idea in theory. The main cited study of Nissen surgical success rates shows that 73% (after ten years) of people that have had the surgery are “cured” of their GERD (out of a very small sample size of 249 people), which is a great thing, right? 29

But the problem with gastrointestinal reflux surgeries is that most people who have had them are now left with a host of other issues, some not reversible. Some of the issues include:30

  • Reflux and regurgitation (known as Nissen surgical failure, yes I know the surgery is supposed to prevent it, but for many it does not)
  • “Gas” bloat syndrome
  • Delayed gastric emptying (vagus nerve damage)
  • Gastroparesis
  • Weight loss
  • Dysphagia
  • Abdominal adhesions
  • Difficult or absent ability to vomit
  • Gastric dumping syndrome
  • Gastic cardia (Roemheld) syndrome
  • Early fullness (satiety)
  • Dysautonomia (may only worsen)
  • Chest pain
  • Death (one to two percent possibility per study)

A fundoplication can also become undone over time and occurs on average in about 10% of the people that have had the surgery, requiring it to be redone.31 “Gas” bloat syndrome is a syndrome where the stomach cannot properly expel gas through burping, and even in some extreme cases a person can even burp or vomit at all which can cause extreme pain. “Gas” bloat syndrome has about a 41% occurrence rate in people who have had a Nissen done and though for some it may reduce in two months; occasionally some people have it until the surgery is either redone or reversed.32 Gastric dumping syndrome rarely occurs when the stomach dumps its contents into the duodenum before complete digestion has taken place leading to, inflammation, diarrhea, and hypoglycemia.33 Finally, since the surgery does not correct the dysbiosis which is the cause of most people’s reflux, their GERD eventually comes back within a few months as consistent pressure from bloating weakens the Nissen over time. A friend joined the Nissen group on Facebook and has been sending me comments of people that have regretted getting it done. He has sent me hundreds if not thousands over the span of a couple of years. This surgery should be avoided at all costs!

The incidence of postoperative failure is 2 to 30%. The frequency of post-fundoplication paraesophageal hernia is 7% and reoperation may be necessary if clinical response is not good. Reoperation frequency is 4 to 9%, but the fact that postoperative dysphagia is very high (33%) must be taken into consideration. Ascending migration of the fundoplication towards the thorax can be progressive and life-threatening for the patient. Other authors have reported reintervention rates of 1.8 to 10.8% for persistent dysphagia34

What about the TIF prodcedure?

The transoral incisionless fundoplication or TIF procedure is different than a traditional Nissen in that it does not require any incision to perform the fundoplication. TIF is an endoscopic technique performed using the EsophyX device which an endoscope and a tissue retractor is placed down the esophagus through the oral cavity. The tissue retractor creates a full-thickness serosa-serosa plication at the Z-line where the LES is located. The procedure, performed under general anesthesia in an endoscopy room, constructs a valve three to five centimeters in length and 200 to 300 degrees in circumference using fasteners. If you have a hiatal hernia suction can be applied by the device to pull the stomach downwards, correcting the stomach’s anatomical position. Additionally, TIF is an outpatient procedure, performed by a gastroenterologist or surgeon in an endoscopy room, and should not take more than sixty minutes to complete.35 36 37

If there is no other choice and you had to get a fundoplication, this is the procedure I reluctantly recommend. The TIF procedure appears to cause less scarring than a Nissen fundoplication and recovery rates seems to be better because of the less invasive surgery being performed. Studies have shown that approximately 3% to 10% of patients who undergo TIF will experience an adverse event. Some of the more concerning side effects of TIF include a mucosal tear, perforation, bleeding, pneumothorax, and mediastinal abscess, however, they are rare and are side effects of any LES strengthening procedure. With the TIF procedure the chance of developing gas bloat syndrome is reduced or eliminated compared to a standard fundoplication, and the chances of the TIF becoming undone are lower. TIF like most LES strengthening procedures does not last forever because it does not correct the underlying problem for most which is upper gut dysbiosis, so reflux does reoccur for most eventually in some degree of severity. Finally, I recommend the newer TIF-2 procedure performed (again if you must) which is a modification of the TIF-1 which entails placement of gastroesophageal plications to create a partial anterior esophagogastric fundoplication above the Z-line.38 39 40

TIF PPI Results

So What Can Be Done for GERD Relief??

Since there are many different causes of GERD there is not one protocol that will help you find relief. For some people, it can be a simple as taking D-limonene every other day for dinner for two weeks. For others, it can take months to relieve a difficult SIBO case. However, I would read the blog articles (linked to the individual causes above) I have written on the many different causes of GERD, and if you believe any of them are causing your GERD work on fixing them. Finally, listen to the above Fix Your Gut podcast on reflux to gain more wisdom on how to improve your digestive health, work with an integrative health care professional, or contact me for coaching and let us resolve your reflux.

  1. http://chriskresser.com/the-hidden-causes-of-heartburn-and-gerd
  2. http://www.siboinfo.com/symptoms.html
  3. http://gut.bmj.com/content/54/suppl_1/i13.full
  4. http://chriskresser.com/fodmaps-could-common-foods-be-harming-your-digestive-health
  5. http://chriskresser.com/are-gmos-safe
  6. http://www.webmd.com/ahrq/treating-acid-reflux-disease-with-diet-lifestyle-changes
  7. http://www.ucdmc.ucdavis.edu/welcome/features/20081204_heartburn/index.html
  8. http://www.ecaware.org/what-is-esophageal-cancer/risk-factors/acid-reflux-gerd/
  9. Rubin, Jordan/Brasco, Joesph. Restoring Your Digestive Health,Twin Streams Publishing, 2003.
  10. http://www.drlwilson.com/articles/candida.htm
  11. Rubin, Jordan/Brasco, Joesph. Restoring Your Digestive Health,Twin Streams Publishing, 2003.
  12. http://www.bobcotton.com/gerdsalt.htm
  13. Balch, Phyllis. Prescription for Nutritional Healing, Avery Publishing, 2010.
  14. http://www.westonaprice.org/digestive-disorders/acid-reflux-a-red-flag
  15. http://www.slate.com/articles/health_and_science/science/2010/08/dont_just_sit_there.html
  16. http://www.preventionandhealing.com/articles/Acid_Reflux_and_Rebellious_Stomach-NEW.pdf
  17. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  18. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  19. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886361/
  21. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886361/
  22. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886361/
  23. http://www.fda.gov/drugs/drugsafety/ucm245011.htm
  24. http://www.ncbi.nlm.nih.gov/pubmed/21121928
  25. http://www.ncbi.nlm.nih.gov/pubmed/21128930
  26. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  27. Dr. Brownsetin, David, Drugs That Don’t Work and Natural Therapies that Do!, Medical Alternative Press, 2007
  28. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  29. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  30. https://www.sciencedirect.com/science/article/pii/S2255534X17300063
  31. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006
  32. http://www.hon.ch/OESO/books/Vol_6_Barrett_s_Esophagus/Articles/vol2/art023.html
  33. Beers, Mark, The Merck Manual, Merck Research Laboratories, 2006″
  34. https://www.sciencedirect.com/science/article/pii/S2255534X17300063
  35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4894777/
  36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271216/
  37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5390325/
  38. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4894777/
  39. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271216/
  40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5390325/
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