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Remember the commercial: “I can’t believe I ate the WHOLE thing!”? Familiar with the frequent ads for Tums and similar medicines for heartburn?
When we have heartburn, we might have to limit what we eat, or how much we eat, or when we eat…and food is supposed to be a fun experience, right?
Sometimes we cringe if someone in church jokes about “my heart did burn within me.” It’s a bit too close to home when we struggle with reflux, or, to use the official name, Gastroesophageal Reflux Disease (GERD).
How Our Body Speaks Through Heartburn: Physiology of Digestion
When we eat, the chewed food passes from our mouth to the esophagus, through a mechanism we call swallowing. The epiglottis closes so food and fluid do not get into the trachea and lungs. Muscles in the esophagus convey the bolus of food, drink or medicine to the stomach. A sphincter at the junction of the esophagus and stomach opens to permit the bolus to enter the stomach. Normally, this sphincter is closed unless food or drink is passing or vomiting takes place.
If the sphincter (called the gastroesophageal sphincter) does not properly close, it permits stomach contents to reflux into the esophagus. That’s when we experience heartburn, but in reality our body is talking to us about a problem it is dealing with. We have to understand both the physiology and the solutions so we can feel better and work in harmony with our body.
Why Our Stomach Does What it Does
The purpose of the stomach is to start the digestive process by churning and releasing acid to break down proteins. The stomach lining is specially created to tolerate this acidic environment. The acid is harmful to the lining of the esophagus.
Symptoms of reflux include heartburn, often described as chest pain. The pain comes from the acid burning the lining of the esophagus. Another common symptom is to taste the regurgitated stomach contents in the mouth. Nausea is also a symptom, but an uncommon one, of reflux.
What Can Happen Over Time Without Treatment
Long-term complications of unresolved reflux affect the esophagus and trachea/bronchi/lungs. The acid burn may create ulcers in the esophagus. Long-term inflammation may cause scar tissue and strictures in the esophagus, thus interfering with swallowing. Recurrent acid exposure to the lower esophagus causes the cells to change in order to be more resistant to acid damage. This change turns normal esophageal cells into a different resistant cell structure called Barrett’s esophagus. If unchecked, continual cell change may result in esophageal cancer.
What Causes Heartburn?
So, what causes reflux? A number of things contribute to it, but ultimately it is a dysfunction of the gastroesophageal sphincter. It remains open instead of closing as it should. This can be from laxity (poor muscle strength) or prolonged opening with swallowing.
There are many factors that can contribute to making reflux worse. They include:
- distention of stomach, caused by eating too much food
- impaired gastric emptying from:
- tricyclic antidepressants
- calcium channel blockers
- nicotine (this also reduces clearance of acid from the esophagus)
- dopamine agonists
- poor or weak stomach muscle contractions, called gastroparesis
- hiatal hernia, which changes the placement of the sphincter relative to the diaphragm so it doesn’t function as well
- difficulty clearing acid from the esophagus due to poor muscle contractions
- certain foods seem to contribute, including:
- fatty foods
- poor digestion in stomach due to insufficient acid production
Evaluation and Diagnosis
The evaluation and diagnosis of reflux can be simple or complicated. Often the symptoms are classic, and a response to treatment establishes the diagnosis.
Additional information can be gained through endoscopy, a flexible tube with a camera inserted into the esophagus and stomach to see what is going on. With endoscopy we can see ulcers, inflammation, and cell changes and then confirm their presence with biopsy. A barium swallow X-ray can check the motility of the esophageal muscles, the status of the sphincter and time to stomach emptying. Ulcers can also be seen with a barium swallow.
There are also pH transmitters that can be swallowed to assess the ability of the stomach to produce acid and clear the acid. Some have a string attached so they can be pulled out, while others are permitted to pass through in the stool.
Treatment is divided into 3 categories:
- common sense items that everyone should do
- conventional medicine drugs and surgery
- functional medicine options
Common sense items that everyone should try and continue doing if they help:
- elevate head of bed at night so gravity helps the reflux to go back into the stomach
- smaller meals frequently
- early evening meal
- avoid offending foods, which may include:
- fatty foods
- spicy foods
- acid containing foods-citrus, carbonated, tomato juice
- avoid smoking
- chew gum, which stimulates bicarbonate swallowing in saliva
Conventional medicine treatment include medications which reduce the acid content in the stomach through several mechanisms:
- antacids to neutralize the acid
- histamine antagonists which block acid production—Tagamet, Zantac, Pepcid
- proton pump inhibitors which block acid secretion—Prilosec, Prevacid, Nexium, Protonix
They also have a medication that helps the motility (muscle contractions) of the esophagus and stomach—Reglan (metoclopramide). They also have a foam barrier that also acts as an antacid called Gaviscon. Unfortunately, it has aluminum in it.
Surgery is reserved as a last resort. This is called fundoplication. It involves tightening the gastroesophageal sphincter. Traditionally this involves wrapping the upper portion of the stomach (the fundus) around the lower esophagus, thus strengthening the sphincter. Variations of that procedure can be done through the endoscope without opening up the abdomen or chest.
How Does a Doctor Like Me Treat GERD?
Functional medicine focuses on strengthening the physiology or function of the stomach and its sphincter. These principles include:
- assist in digestion of food so it passes through the stomach in a timely fashion
- pancreatic digestive enzymes
- betaine HCl to increase acid production
- bile if gall bladder is absent
- DGL (deglycyrrizinated licorice) to increase protective mucus production in stomach lining
- treat food allergies
- Nux vomica—homeopathic that tightens the gastroesophageal sphincter. The product made by Heel works the best.
- drink at least 8 cups of water per day
I have compiled a list of 6 rules of eating which should also help with reflux.
- eat only when hungry
- stop eating when hunger is resolved (not when ‘full’)
- chew each bite until it is liquid
- savor each bite (enjoy the flavors)
- relax, be cheerful when eating
- focus on eating (no TV, reading paper)
Most of the functional abnormalities in the body will resolve when we understand and work with the our body’s physiology. If we listen carefully to what our bodies are telling us, we can attain a much higher level of health. Try it and see.
Dr. Gardner, board certified in Anti-Aging and Regenerative Medicine and a Certified Nutrition Specialist, works out of his Riverton office, Keys to Healing Medical Center. He can be reached at (801) 302-5397 for appointments.