by Jason D. Gourlas, PA-C
Gastroesophageal reflux disease (GERD) is a chronic digestive disorder in which stomach contents (food or liquid) leak back into the esophagus (the tube leading from the mouth to the stomach). Many people suffer from this condition, making it is the most common diagnosis of all presenting gastrointestinal complaints.
Between 14-20 percent of U.S. adults have some form of GERD, and we spend more than $10 billion each year on proton pump inhibitors (PPIs) like Nexium® and Prilosec®. Despite the use of these PPIs, the incidence of esophageal cancer, a complication of prolonged and severe reflux, has been increasing significantly during the past 20 years.
In normal digestion, food passes from the esophagus to the stomach through the lower esophageal sphincter (LES) which is a ring of muscle between the esophagus and the stomach. The LES then closes to prevent food and acidic stomach juices from flowing back into the esophagus. GERD occurs when the LES is weak or relaxes inappropriately. Reasons for this weakening or relaxing of the LES can include obesity, pregnancy, poor digestion and back-up from poor forward movement of the intestines. Certain substances like caffeine, chocolate, onions, peppermint, garlic, alcohol and nicotine can relax the LES. A hiatal hernia is another potential cause of GERD. A hiatal hernia occurs when a portion of the stomach pushes up into the chest through the diaphragm (the muscle separating the abdomen from the chest). This can occur as a result of straining, coughing, vomiting or sudden physical exertion.
What’s important to note is that GERD isn’t so much a problem of acid overproduction as it is one of inappropriate acid location. Chronic use of acid blocking medications can result in many problems. Stomach acid is one of the first lines of defense against infection. People on acid blocking medications have a higher risk of infections including pneumonia, Clostridium difficile (antibiotic associated colitis) and small intestinal bacteria and yeast overgrowth. Stomach acid is also necessary for proper digestion of proteins, mineral absorption (calcium, magnesium, etc.) and the liberation and absorption of B vitamins. These deficiencies can lead to osteoporosis, anemia, nerve damage and a host of other disease processes.
While heartburn, regurgitation and difficulty swallowing are the most common GERD-related complaints, GERD can manifest a variety of other symptoms including laryngitis, chronic cough, asthma, ear infections, erosions of the teeth and the sensation of a lump in the throat. GERD can be a common cause of unexplained sleep disturbances. It can even mimic the chest pain that comes as a result of a heart attack with radiation of the pain to the back, neck, jaw and arms. Prolonged reflux can result in erosions of the esophagus, precancerous changes (known as Barrett’s esophagus) and esophageal cancer.
Diagnosis and Treatment
Given the many faces of GERD, a high index of suspicion is necessary to make an accurate diagnosis. This comes from diagnostic testing and a look at one’s medical history. There are some special studies that can assist in the diagnosis. Some of these tests include 24-hour acid monitoring via a probe in the esophagus, measurement of the pressure in the LES, and endoscopy (looking in the esophagus and stomach with a fiber optic camera). Uncontrollable GERD symptoms mandate evaluation by endoscopy.
Practical measures include avoiding wearing tight clothing, weight loss, avoiding foods that lower the LES pressure, not lying down within three hours after eating, eating smaller, more frequent meals, and chewing food thoroughly. Placing 6-9- inch blocks under the head of the bed can use gravity to keep stomach contents where they belong. Stress causes reduction in the forward flow of the GI tract; stress reduction measures can mitigate this.
Some supplements have been found to be useful in treating GERD. Melatonin, better known for its effect on sleep, is found at a concentration 400 times greater in the GI tract than in the brain. It tightens the LES, increases forward flow in the intestines, and modulates acid production. D-limonene found in citrus oils can increase GI movement, and it protects tissues from acid. These supplements may need up to six weeks to reach maximum efficacy. Probiotics help digestion and GI motility. Digestive enzymes improve digestion. Sometimes, it is even necessary to supplement stomach acid (in the form of betaine HCl) to improve digestion. This should be done cautiously and should be avoided in patients with active ulcer disease and/or erosions. Finally, supplements like aloe vera, slippery elm and marshmallow root can coat and soothe inflamed tissues.
The goal should be normalization of the function of the GI tract. Blocking acid production runs contrary to this. Acid blocking medications should be avoided if possible and used if the above measures are found to be ineffective. If you are already on an acid blocking agent, you should discuss your options with your healthcare provider.
Jason D. Gourlas, PA-C, practices at Vital Life Wellness Center, located at 2520 Broadway, Suite 100, in San Antonio. He has 22 years of experience in medicine, which includes primary care, emergency medicine, neurology and surgical critical care in hospital, clinic and military settings. He is board certified through the National Commission on Certification of Physician Assistants, a member of The Institute of Functional Medicine and is seeking board certification in functional and restorative medicine with the American Academy of Anti-Aging Medicine. Gourlas also served 15 years in the United States Army. For more information about Vital Life Wellness Center, including information on free seminars, visit www.vitallifewellness.com or call 210-595-1019.