Updated: Feb 16, 2020
Were you aware that your reflux and heartburn symptoms are most likely NOT due to excess stomach acid? Although acid lowering drugs like Losec (Omeprazole), Mylanta & Gaviscon can do a great job of relieving your symptoms they aren't actually addressing the underlying cause.
So what are the underlying causes of gastro-oesophageal reflux (GORD) and what can you do differently to heal and prevent the symptoms?
Most of us have experienced some kind of indigestion or heartburn at some point in our adult life. Maybe after pigging out on a huge plate of greasy fish 'n' chips?
Heartburn is that awful burning feeling which rises from the upper stomach or lower chest up towards the neck. If it occurs around twice a week it is considered acid reflux. More than twice a week, it is called GORD (or GERD in the US).
Other common symptoms of GORD include:
pain in the upper abdomen and chest
an acid taste in the mouth
nausea or a sick feeling
burning pain when you swallow hot drinks
Less common symptoms include:
A persistent cough (particularly at night)
Abdominal pain and/or bloating
Enamel erosion of the teeth and frequent cavities
Regurgitation of food after eating
Sleep issues such as sleep apnoea
Recurrent ear infections, sinusitis and pharyngitis.
To understand the causes we must first understand how digestion works.
Just thinking of a delicious piece of chocolate cake kicks our stomach and mouth salivary glands into action. This is our body's way of preparing itself for the essential task of digestion.
Digestion allows us to convert food into energy and the vital nutrients required for our body to function. A large number of organs are involved, from our mouth (and brain), all the way down to our anus.
In our mouth, saliva contains enzymes to help break down food into smaller particles we can absorb and use. Any swallowed food and saliva reaches the stomach by way of wave like motions along a long tube called the oesophagus.
Once in our stomach, the food is further broken down by digestive enzymes.
One potent enzyme, pepsin, breaks down proteins but it requires adequate hydrochloric acid to become active. Hydrochloric acid is produced by the cells in the stomach wall, however, it is reliant on adequate levels of zinc, vitamin B1 and B6.
Around three times after each meal the contents of our stomach very briefly reflux up into the oesophagus. Swallowed saliva helps to neutralize the acidic contents and prevent any damage to the oesophagus.
A bundle of muscles called the lower oesophageal sphincter (LOS or LES in the US) normally helps prevent any prolonged or frequent reflux. So effectively anything that interferes with the normal opening and closing of this sphincter has the ability to cause the symptoms of reflux or GORD. Though reflux symptoms can also be due to a lack of protective mechanisms for the oesophagus such as a lack of saliva production or a damaged oesophageal lining.
The most common treatment of GORD involves the use of acid lowering drugs. Some are over-the-counter antacids like Mylanta, Gaviscon or QuickEz, or H2-receptor blockers like Ranitidine and Cimetidine. A more heavy hitter is the drug Omeprazole, also known as Losec. It is the third most dispensed drug in New Zealand.
These medications aim to neutralize, reduce or block stomach acid production. However, an overproduction of stomach acid is rarely the underlying cause, and instead only address the symptoms. There are dangers to the overuse of these medications too. You can read more about that here.
What are the common underlying causes of GORD?
You will see there are multiple, often connected causes, and the possibility of more than one being responsible for the symptoms.
Low stomach acid (Hydrochlorhydria)
A low stomach acid level is actually more common than high. The lower oesophageal sphincter will close when it "senses" an adequate acid concentration, but will remain open if the stomach doesn't reach the proper level of acidity.
Conversely, the pyloric sphincter which holds the stomach contents in until it is ready to move to the intestines, will not open unless the acidity has reached a sufficient level. The food can then remain in the stomach longer resulting in indigestion, bloating and reflux of the stomach contents.
There are further consequences of low stomach acid, such as an increased risk of infection. Stomach acid offers protection by eliminating bacteria, viruses and parasites in the stomach.
As mentioned earlier hydrochloric acid is needed to convert the enzyme pepsinogen to pepsin in order to digest proteins. If this doesn't occur low pepsin levels can lead to digestive complaints. Undigested proteins can also cause an immune and inflammatory response if they manage to "leak" through the gaps between the cells in the small intestine.
Asthma, allergies and gallstones are also correlated with low stomach acid.
Stress, smoking, alcohol, medications (such as omeprazole or Losec), nutrient deficiencies (such as zinc, vitamin B6 and B1), a Helicobacter Pylori infection, gallbladder or pancreatic issues, and surgery (eg. gastric bypass) can all reduce the production of stomach acid.
Food intolerances, sensitivities or allergies
Poor digestion and inflammatory responses can lead to a "leaky gut" and further nutrient deficiencies and immune reactions.
Infections in the gut
The bacterial infection Helicobacter Pylori can cause stomach ulcers and lower stomach acid production. There are a number of tests your GP can do to determine if H. Pylori is an issue for you.
Structural defects that cause any restriction in the stomach area.
Some examples include a hiatal hernia, congenital malformations, scar tissue, connective tissue disorders and previous surgery (eg. gastric bypass surgery). A hiatal hernia is where the upper part of the stomach is pushed up into the upper chest cavity through a hole in the diaphragm, disrupting the functioning of the lower oesophageal sphincter.
Further tests such as an endoscopy may be required to determine if there are structural defects in the stomach, oesophagus or the sphincter between the two. An endoscopy or pH monitoring test can also indicate how severe the GORD is or if there is any damage to the oesophagus.
However, most patients with GORD will not have oesophageal abnormalities on endoscopy.
Overeating and Excessive weight
Increased stomach pressure from overeating or excessive weight prolongs the relaxations of the lower oesophageal sphincter, allowing stomach contents to reflux into the oesophagus.
Small Intestinal Bacterial Overgrowth (SIBO)
The increased bacterial population in the gut causes excessive gas production. Pressure can then build in the stomach which can be enough to overpower the lower oesophageal sphincter.
Any condition that causes delayed gastric emptying & issues with gastric motility.
When the stomach stays full and distended for a prolonged time it can cause pressure on the lower oesophageal sphincter. Examples include diabetes, gluten reactions, (post) viral infections, and previous surgery.
Issues with the normal defence mechanisms of the body such as with saliva production or the lining of the oesophagus (eg. in Sjogren's disease).
Issues with the vagus nerve
The vagus nerve is the longest cranial nerve and the "head honcho" when it comes to involuntary regulation of important body processes including digestion and heart rate. Damage from a previous surgery, diabetes mellitus, cranial faults, poor spine and nerve function can all impact the vagus nerve.
Prevention, management and treatment
Addressing the underlying cause should always be the priority.
Is a food intolerance or allergy a factor?
Could a spinal adjustment and/or visceral manipulation be of benefit? (Not all chiropractors know how to perform visceral manipulation, you'll need to ask around).
Is there a specific structural issue detected on endoscopy that could be helped by surgery?
Are you taking a medication that can exacerbate symptoms of GORD? E.g. calcium-channel blockers, beta-blockers, benzodiazepines, tricyclic antidepressants and anticholinergics. You can also look for the side effects of any drug by googling its Medsafe data sheet.
Are you deficient in nutrients needed to produce stomach acid (hydrochloric acid) such as zinc, vitamin B1 and B6?
Do you have Helicobacter Pylori?
Do you have symptoms of Irritable bowel syndrome and SIBO? Do you need to address a small intestinal bacterial overgrowth?
Or maybe you just need to lose weight, stop smoking or cut out the C.R.A.P.!
Dr Sherry Rogers, author of “No more heartburn” suggests cutting out…
C – Coffee, cigarettes, & chocolate.
R – Refined carbohydrates (i.e. sugar filled foods, bread, pasta, pastry, cakes, biscuits etc), RX (some medications).
A – Acid foods (such as tomatoes and citrus), alcohol, allergic (or intolerant/sensitive) foods.
P – Peppermint & progesterone (as are muscle relaxants), pop (soda), and packin’ food before bedtime.
It is also recommended you…
Increase your fruit and vegetable intake.
Reduce any excess weight you are carrying.
Avoid highly processed & fatty fried foods.
Eat smaller meals more often.
Chew your food thoroughly and slowly eat your meals.
Don't lie down (stay upright) for at least a few hours after a meal.
Don't smoke - it weakens the lower oesophageal sphincter.
Don't eat before strenuous exercise.
Only once the underlying cause(s) of the GORD have been addressed should antacid medications, especially proton pump inhibitors like Losec, be very slowly decreased to the point of withdrawal. It is common when coming off this medication for there to be a sudden increase in stomach acid production, worsening symptoms.
For natural symptom relief or healing, the following have been suggested:
But, please check with your health practitioner first.
Slippery elm powder - this can be a great first aid remedy for reflux. Drink mixed with water so it becomes a slurry to coat the oesophagus.
Curcumin (Turmeric) - may reduce inflammation and oxidative stress.
Nux vomica - This homeopathic remedy is especially beneficial for those with nausea, bloating, sour burping and indigestion. It is also one to consider if symptoms are aggravated by spicy, rich foods and in those that are impatient, irritable and tend to overeat.
Deglycerized licorice (or DGL) - taken as chewable tablets prior to a meal to coat the stomach and prevent reflux.
Aloe vera inner leaf extract or juice - Used to reduce irritability of the oesophageal lining and aid healing.
Zinc - helps with digestion, stomach acid production and healing of the gut lining.
Glutamine - aids healing of the mucosal lining.
Digestive or Pancreatic enzymes (eg. betaine HCl) or bitters taken with meals - aids digestion and decreases distension of the stomach.
Phosphatidylcholine - used to increase the neurotransmitter acetylcholine, which may improve the tone of the sphincters and improve gastrointestinal motility.
Calcium citrate powder - may also improve the tone of the LES - 250 mg, dissolved in water, after every meal and at bedtime (for a total daily dose of 1,000 mg)
Iberogast &/or Ginger - may be beneficial for those with poor gastric motility, diabetes and small intestinal bacterial overgrowth (SIBO).
Long-term use of stomach acid reducing medications should rarely be needed if the underlying cause is sought and addressed. Many of the causes can have a major impact on other areas of your health also, so please consider seeking help from a holistic or functional medicine practitioner if you are a sufferer of heartburn or reflux.
Join my IBS & Gut Healing Support Group here.
Learn more about the dangers of Losec, Omeprazole & other medications for reflux and heartburn head here.
Need to check out the references? Here you go...
The Ups and Down of Reflux Webinar by Dr Sandberg-Lewis ND, DHANP for The Functional Medicine University