- From the Desk of Dr.Brkich
Gastroesophageal Reflux Disease (GERD)
The medical definition of Gastroesophageal Reflux Disease (GERD) is regurgitation, or reflux, of too much acid from the stomach back up into the esophagus. Medscape, a website that provides medical information and continuing education for doctors, states that “gastroesophageal reflux disease (GERD) occurs when an excess of gastric juice refluxes into the esophagus”.
The cause of acid reflux is widely assumed to be too much stomach acid. The assumption goes unquestioned because it appears self-evident and makes sense logically. Heartburn sufferers get relief when they take antacids or drugs that inhibit the production of stomach acid, and this is used as proof that too much acid is the cause of the reflux. Unfortunately, this is a specious conclusion that is neither supported by science nor consistent with what I have observed in practice. The definition of specious is having the ring of truth but is actually fallacious. It is a wrong conclusion that sounds plausible but is false. Too much stomach acid (hyperchlorhydria) is very rare. Not enough stomach acid (hypochlorhydria) is far more common. The assumption that acid reflux is caused by too much stomach acid unfortunately results in unnecessary consequences from long term acid suppression, ultimately leading to increased morbidity (disease) and mortality (death).
The Purpose of Stomach Acid
Stomach acid is essential for digestion of food and absorption of nutrients. Without adequate hydrochloric acid in the stomach, digestion cannot take place. Undigested food simply stays in the stomach for too long. This is called gastroparesis, a disorder of stomach motility. Food in the stomach cannot move downward into the small intestine until the pH in the stomach is acidic enough. Low stomach acid results in the food just sitting in the stomach, going nowhere. Instead of being digested by the body’s own digestive enzymes, which depend on high acid in the stomach, the undigested food is broken down by microbes. Microbes, such as bacteria and yeast, produce gas and toxins as they ferment and putrefy (rot) the food. The less acid in the stomach, and the longer the food stays in the stomach, the more gas is produced by the microbes, as the rotting continues.
The amount of pressure from gas in the stomach can get quite high. If both valves of the stomach remain closed, the gas becomes trapped in the stomach and has nowhere to go, neither up nor down. The gas forces the stomach to expand and push up against the diaphragm. Sometimes the top portion of the stomach is squeezed upward through the diaphragm, called a hiatus hernia. Expansion and contraction of the diaphragm is what enables breathing. Pressure on the diaphragm by an expanding stomach can inhibit breathing if the diaphragm is unable to expand downward because of the distending stomach pushing up against it. The more food that sits in the stomach, the more gas is produced by the microbes, and the more pressure is exerted against the diaphragm. If the diaphragm can’t expand, breathing can become impaired.
In addition to breathing impairment, the pressure exerted on the diaphragm can force open the one-way valve between the esophagus and the stomach. Stomach contents can reflux backwards up the esophagus, into the throat, and can be inhaled into the lungs. Even a small amount of acid from the stomach can be extremely irritating to tissues that are not designed to withstand acid. The stomach is the only organ that can tolerate acid and is designed to tolerate very strong acid to function properly. Stomach acid is supposed to be very strong in a healthy person and is often compared to acid in a car battery which can cause severe burns. Even a small amount of acid inhaled into the lungs can cause a reaction mimicking asthma. Acid reflux into the esophagus can cause excruciating chest pain. Many acid reflux sufferers go to emergency, thinking they are having a heart attack.
Is suppressing stomach acid the best way to treat heartburn?
In the short term, suppression of stomach acid may be necessary, but definitely not long term. As soon as the acute symptoms are managed and controlled, the cause of the acid reflux needs to be investigated and treatment of the cause (not just symptoms) must be initiated to eliminate the reflux. Treating the symptoms of acid reflux is necessary but not sufficient. Long term suppression of stomach acid is associated with an increased risk of numerous diseases and conditions, some of which are dementia, kidney failure, osteoporosis, infections, immune suppression, irritable bowel syndrome, and ultimately the breakdown of the intestinal mucus barrier, leading to increased intestinal permeability, commonly known as “leaky gut” which is the gateway of most, if not all, metabolic and inflammatory diseases. It is very important to treat the underlying cause of acid reflux as soon as possible.
Chronic acid reflux left untreated can cause serious complications such as Barrett’s Esophagus, for example, which is a precancerous condition.
Why is suppression of stomach acid production not a good solution?
Suppression of stomach acid causes disease because it impairs digestion. Stomach acid is absolutely essential for digestion. Without hydrochloric acid in the stomach, digestion is impaired, not only in the stomach, but also in the pancreas, small intestine, gallbladder, and liver, all of which together orchestrate the entire digestive process. All digestion starts in the stomach and is dependent on stomach acid. Imagine a conveyor belt in an assembly line. If one worker on the assembly line does a poor job, then the others down the line cannot do their job properly, and the end result is a faulty product. In the body things are even worse. The rest of the line can do nothing without stomach acid. The liver, gallbladder, pancreas, and small intestine cannot function without stomach acid. Without stomach acid, the entire process of digestion can grind to a halt.
What are the consequences of poor digestion?
Normally food is first digested by hydrochloric acid and pepsin in the stomach, then by digestive enzymes from the pancreas and small intestine, and finally, by bile from the liver and gallbladder. Adequate digestion of food by the body’s own inherent digestive processes is essential for proper absorption of nutrients such as vitamins, minerals, amino acids, and antioxidants.
Digestion by our body’s own digestive enzymes is clean and nontoxic. Fermentation and putrefaction of undigested food by bacteria and yeast is essentially rotting of food. Rotting food is toxic and unhealthy. We would never think of eating rotting food. Yet, even the highest quality organic food can be turned into toxic poison by microbial fermentation and putrefaction in the wrong places. Stomach acid is critical for preventing food from rotting in the digestive tract. Antacids and acid suppressing drugs such as histamine 2 receptor antagonists and proton pump inhibitors used long term inhibit digestion and promote the rotting of food throughout the digestive tract. The byproducts of rotting food can be toxic to the gut microbiome. The most toxic and inflammatory are the lipopolysaccharides produced by gram negative bacteria. These toxins form the basis of numerous metabolic diseases.
Many people experience relief from heartburn and acid reflux by simply adding apple cider vinegar to their meals or by taking bitters before meals as a way of stimulating acid production by the stomach. Serious GERD requires more extensive measures. With any symptomatic treatment, caution must be taken to not aggravate inflammation of the esophagus (esophagitis) or stomach inflammation (gastritis). Helicobacter pylori infection must always be ruled out.
One should never abruptly stop acid suppressing medications without medical supervision. Abruptly stopping these can lead to rebound hyperchlorhydria, where too much acid is indeed produced, causing further aggravation of an already inflamed condition. The esophagus, unlike the stomach, is not meant to tolerate acid. Even small amounts of stomach acid can cause severe pain anywhere outside the stomach. Not enough acid for digestion can still be more than enough to cause pain from reflux. This further reinforces the myth that it is too much acid that is the cause of reflux.
Gastroesophageal Reflux Disease (GERD) is always a symptom of some other underlying condition. It is always associated with an imbalance in the microbiome, called dysbiosis. Addressing and treating the cause of the dysbiosis, in my view, makes much more sense than symptomatic suppression of stomach acid, which ultimately and inevitably lays the groundwork for long-term, unintended and unrecognized negative health consequences.