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Dealing with Gastroesophageal Reflux
Gastroesophageal Reflux, what we experience as “heartburn”, involves the regurgitation of stomach acid into the esophagus, producing a burning sensation, or into the throat, producing cough. Reflux begins as a nuisance, but can evolve in to a state of chronic inflammation (Barretts’s Esophagus), a potential setting for malignant transformation.
Your SYMPTOMS are due to stomach acid, so we physicians give you drugs to WIPE OUT the production of stomach acid (these are the “purple pills” available by prescription and now over-the-counter). You do feel better and inflammation is attenuated, so there is a benefit here – but there is also a price – your digestive/nutritional assimilation capacity and defense against food borne illness will be compromised – because we dealt with SYMPTOMS and not the CAUSE.
The cause of reflux is insufficient gastric acid production – that’s right - not enough gastric acid is being produced. We generate gastric acid in response to eating; the acid breaks down protein such that it can be further digested and assimilated within the small intestines. The gastroesophageal sphincter (the one-way valve) is a muscular ring within the wall of the esophagus as it attaches to the stomach. It opens to allow swallowing – this makes sense. It closes to prevent partially digested stomach contents and gastric acid from refluxing back in to the esophagus – this makes sense too. Eating triggers closure of the GE sphincter, and the biochemical signal for sphincter closure is a rising acid level (a low pH) within the stomach. We need acid to close the one-way valve. Stated otherwise, without sufficient gastric acid production, the valve will not close and we will experience heartburn.
Insufficient gastric acid production (hypochlorhydria) is common. It is seen in association with several medical conditions (including asthma in kids), rises in frequency as we age, and may be the norm in seniors – and this is the cause of your reflux. We eat, we don’t make enough stomach acid, the sphincter does not close, and we reflux. We complain to our spouse, who saw the TV adds about Gastroesophageal Reflux DISEASE, and then we demand a purple pill – and we get one - we do feel better, but protein digestion will never be the same, the absorption of key nutrients will be compromised, and stomach acid is no longer available to kill parasites and other critters in our food – this is not an optimal long-term solution!
The above scenario does not apply to everyone. There are people with hiatal hernia, a defect in the muscular diaphragm that allows the upper stomach to rise out of the abdomen, into the chest cavity. Here the problem becomes more mechanical as opposed to biochemical. A hiatal hernia can be addressed surgically, and there is a manipulative technique, utilized by chiropractors and osteopaths, that can pull the stomach back in to the abdomen where it belongs (I do not know how to do this but have seen it work). Also, some of you with “heartburn” may really have H. pylori gastritis, a different entity that requires different therapy. When reflux is long standing and too-far-gone for cause specific therapy, then lifelong acid suppression therapy is necessary. The rest of us can follow the protocol described below, in a step-by-step approach.
Dietary/Mechanical Measures - Don’t overfill your stomach. Avoid foods likely to aggravate reflux (tomato products, chocolate, or any food that bothers you). Avoid vigorous exercise early post-meals and do not lie down immediately after eating. Sleep with the head of your bed elevated on 6 inch blocks – all common sense recommendations.
Quiet The Inflammation - Before beginning HCL/Pepsin therapy, we need to quiet
the inflammation you are currently experiencing, using one or more of the
following approaches:
1. DGL (deglycyrrhizinated licorice) 1-2 tabs, chewed up and swallowed, 4 times
a day and as needed. DGL (if it is chewed up) will mix with saliva to form a
gel that soothes and protects the esophageal/stomach lining. Regular licorice
is inappropriate (its glycyrrhizinic acid component can raise your BP). Stay on
DGL for two works after your symptoms have resolved.
2. EsophaGuard (available through Life Extension (lef.org) contains
D-limonene. This agent, derived from the peel of citrus plants, has a prominent
(and endoscopically proven) anti-inflammatory
affect. A single course of therapy is carried out over 10 days.
3. Probiotic (beneficial bacteria) therapy is helpful. I don’t know how this
works at the level of the stomach but I do know that chronic suppression of
gastric acid will alter the mix of bacteria in your GI tract – to your
detriment, so take a probiotic twice a day.
Acid/Digestive Enzyme Supplementation – So you’ve cleaned up your diet, followed
the mechanical measures outlined above, and put out the fire with the above
preparations (and there are many more – these are simply the ones that we have
been using). Now it’s time to address the cause:
1. Take HCL (hydrochloric acid) with Pepsin (digests protein), 1-4
capsules/tabs with each meal or snack. Large, high protein meals may require
four tabs, a small meal only one – find what works for you. Do not take HCL-Pepsin
on an empty stomach – if you do you will experience a “stomach burn” sensation.
If the capsule gets stuck in throat, wash it down with water.
2. You may also need help with fat digestion. D.A. (digestive aids) #34 by
Carlson, or a similar preparation containing ox bile, will help here, again 1-4
tabs depending on the fat content of the meal and your individual response.
This program will not work for everyone, but I hope that it will work for you.
I do not feel that pharmacological acid suppression therapy to deal with the
symptomatic manifestations of acid deficiency is a physiologically sound
approach. I feel that wiping out stomach acid now may place you at risk for
more significant problems in your future.
James C. Roberts MD FACC 2/15/08