Acid Reflux and GERD

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Sections

Pathophysiology of the Esophageal Diseases

Because the lining of the esophagus is not protected from irritating hydrochloric acid like the stomach lining, even small amounts of acid will irritate the tissues and cause these various problems. Since the stomach lining is protected from caustic levels of high acidity during digestion, but the esophagus is not, the main protection from episodic acid irritation is the lower esophageal sphincter, and stomach dysfunction causes improper opening and closing of this sphincter, resulting in damage to the sphincter, and subsequent damage to the esophageal lining. Attributing this disease mechanism purely to high acidity is a gross oversimplification, and most medical specialists in 2010 now admit that stomach dysfunction is actually the cause of GERD in most cases. Research shows that in many, if not most, cases of reflux, the problem involves deficient excretion of stomach acids with slow emptying of the stomach, and not hypersecretion. With poor stomach function tissue degeneration may occur, allowing small amounts of stomach acids to escape to the esophagaus. Hypochlorydia, or slow and deficient acid production, produces many symptoms that are similar to excess stomach acid conditions, and lack of proper diagnostic consideration often results in a prescription of drugs that inhibit acid production rather than restore function. Although any inhibition of acid production may temporarily relieve symptoms, the condition is not being treated properly, and the consequences may be severe.

It is now recognized that a large percentage of esophageal reflux can be attributed to transient lower esophageal sphincter relaxations (TLESR), and that most of these occur due to insufficient timely emptying of the stomach contents into the small intestine, and gastric distention. These transient lower esophageal sphincter relaxations may last for 10 to 30 seconds. The solution to this problem is to restore the mechanisms of timely stomach emptying, which is a feedback mechanism.

Simply inhibiting stomach acid production will do little to solve this problem. Because of these findings, standard medicine and the pharmaceutical industry are now utilizing glutamate receptor antagonists to inhibit the vagal control of transient lower esophageal relaxations. Once again, an allopathic method of inhibiting normal functions may indeed decrease some symptoms for patients, but is not the cure, and will not restore normal homeostatic function, and comes with considerable risk of side effects. Research has revealed that TLESRs occur in healthy individuals, even at about the same frequency as those with GERD. With the occurrence of GERD, though, the TLESRs are much more associated with acid reflux rather than non-acid reflux. This is because with the increase in acidity, the emptying of the gastric contents is delayed in patients with GERD, while in healthy patients, as the stomach reacts to food and produces gastric acids, a cycle of feedback mechanisms occur that stimulates gastric emptying. Restoration of this feedback system and proper stomach emptying is obviously the key to correction of the problem, not inhibiting the production of digestive acids, which in time actually stimulates a response of more cells that produce stomach acid to compensate, resulting in problems with rebound withdrawal when these drugs are discontinued after chronic use.

Transient lower esophageal relaxations (TLESRs) have been found to be affected by specific acupuncture and electroacupuncture stimulation, with reduction in frequency and duration of these events, but this alone also is not the cure. With proper application of Traditional Chinese Medicine (CIM/TCM), this is just one part of the holistic treatment protocol, and achieving a normalizing of the homeostatic mechanisms with herbs, other types of acupuncture stimulation, nutrient medicines, and diet and lifestyle changes, is the effective way to restore healthy homeostasis and end GERD. The failure in clinical treatment with CIM/TCM often involves the failure on the part of the patient to actually take these herbal and nutrient medicines in a step-by-step manner to fully restore the gastrointestinal function, as well as the failure to utilize acupuncture stimulation as it is proven to work, in short repeated courses of frequent needle stimulation, not a single acupuncture treatment every week or two for a while. Proper holistic protocol is the key to success. If PPI drugs have been taken for some time, both a gradual withdrawal of the drug and a restorative holistic treatment protocol needs to be conducted simultaneously. Hopefully, understanding of the pathophysiology of the problem will encourage more patients to utilize the proper treatment and take a more proactive approach to their care.

The acidity in the stomach and small intestine is a variable system that should react to food to insure proper digestion, assimilation of nutrients, and stomach emptying, as well as the proper secretion of digestive enzymes from the pancreas in the small intestine. The relief of symptoms often involves use of chemical medications that block parts of this complex system of feedback regulation, either histamine formation or acid formation with proton pump inhibitors. This is not a cure. Symptom relief may occur, but this does not always signify a cure of the medical condition. A large study in 2013, at the University of Genoa School of Medicine, in Genoa, Italy, found that for scleroderma patients with esophageal motility abnormalities, a problem with small intestine motility in a great percentage of cases. Delayed gastric emptying as associated with both abnormalities in TLESRs and slow transit though the entire gastrointestinal tract (PMID: 23352249). We see that restoration of the entire gastrointestinal function is important to resolve these problems. Use of Complementary and Integrative Medicine (CIM/TCM) to help restore stomach and small intestine function is needed to achieve an end to acid reflux and the side effects of long term use of medications, which include calcium imbalance with increased risk of joint problems and osteoporotic stress fracture, and many other side effects. Often, the symptoms of reflux are due to more than just stomach acidity. Read on to learn what you haven't been told about reflux.

The symptoms of reflux in the esophagus may be due to mechanisms other than hyperacidity in the stomach. In this case, standard medication to inhibit production of stomach acids will be ineffective, and in fact may be worsening the pathology. In this case other approaches are necessary. Much scientific study has been conducted concerning the ineffectiveness of standard medication with chronic use. The Merck Manual (online: see: Electrical Impedance Testing under Gastroparesis) states: “In electrical impedance testing, an electrical sensor is placed in the distal esophagus to assess nonacid reflux, which is common in patients receiving gastric antisecretory drugs and in infants with reflux disease." This statement shows that it is widely accepted that chronic use of medications that block stomach acid secretion may be associated with nonacid reflux in the distal esophagus, and reflux due to low stomach acid, or hypochloridia, has long been noted by the medical establishment, even in infants.

Esophageal reflux is a common problem that involves poor health of the esophageal tissues as well as a reflux that is often associated with chronic asthmatic and allergic conditions. Studies have shown a strong link between allergic asthmatic triggering and failure of the esophagus to prevent reflux, especially at night. This is because the nerve stimulation is similar in both pathologies. Gastroesophageal reflux is a potent asthma trigger, and corticosteroid asthma medications may contribute to GERD.

A study conducted in 2002 by researchers at the University of Alabama at Birmingham concluded that: “Prednisone (a corticosteroid) 60mg/d for 7 days, increased esophageal acid contact times in this small population with stable asthma". The exact mechanism or reason for this increase in esophageal acid reactivity remain unclear, but the researchers concluded that patients with asthma complain of new or worsening esophageal reflux symptoms when treatment with oral corticosteroids is initiated, and this study proved that corticosteroid use worsened acid reactivity in the tissues. Not only the use of corticosteroids in treatment of asthma, especially in inhalers, but now in many diseases, including the growing number of cases of Eosinophilic Esophagitis, often mistakenly diagnosed as GERD, is actually worsening the tissue response to reflux stomach acids. More and more we are seeing patients afflicted by both of these associated problems, GERD and asthma, and yet these adverse risks of standard treatment are ignored.

Other health problems that are now associated with poor stomach function and hypochlorhydria (deficient production of stomach acids), include: food sensitivities, pernicious anemia (B12 deficiency) and iron deficient anemia, mineral deficiencies with hormonal imbalance, osteoporosis, hypothyroidism, autoimmune disorders, allergies, depression, low energy , and various skin disorders, including eczema, acne, and dry itchy skin. Microbial growth in the stomach and intestines is also linked to stomach dysfunction and hypochlorhydria, with overgrowth of Heliobacter pylori, Candida, Clostridium difficile, coliforms, and other microbes becoming increasingly prevalent in the population. Overly simplistic approaches to treatment of GERD and acid reflux may be responsible for a wide variety of growing health problems in our population, compounded by excessive use of antibiotics, pain medications, and corticosteroids. If you are diagnosed with GERD and are taking medications to relieve symptoms, or experience frequent acid reflux and heartburn and are taking drugs to control these symptoms, you should seriously consider utilizing Complementary and Integrative Medicine (CIM/TCM) to restore stomach and GI health as well. The risks of worsening or acquiring a wide variety of common health problems may be significantly reduced if you take the time to work proactively with a Licensed Acupuncturist and herbalist to restore healthy function. The more simple approach of just taking the PPI acid-inhibiting drug every day comes with considerable risk of a wide variety of serious adverse health effects over time.

Differentiation of excess acid and deficient acid conditions

Testing in the hospital and clinical setting is recommended to properly assess stomach acid functions. Unfortunately, current medical guidelines established by the pharmaceutical and insurance industries discourage this practice, and payment for the practice. Symptoms are similar in high acidity reflux and low acidity reflux diseases. Symptoms associated with hypochlorhydia, or low acid dysfunction include: burning feeling in the stomach that is relieved or worsened by eating, lingering heartburn and reflux for up to four hours after eating, bloating, belch and gas immediately after a meal, and a constant gnawing mild hunger. Significant signs that may be evident include: loss of appetite for high protein foods such as meats, bad breath, undigested food in the stool at times, constipation, brittle or soft fingernails, dilated capillaries around the nose and cheeks, nausea when taking supplements and herbs, and nocturnal calf cramps. Of course, not all of these symptoms are required to suspect hypochlorhydia, and the absence of some of the symptoms does not mean that the problem of deficient stomach function does not exist for an individual. Testing for hypochlorhydria is not common in standard practice. Simple at-home tests include drinking a quarter teaspoon of baking soda in a glass of water and timing how long it takes to belch. If the stomach is producing stomach acids quickly enough, one should belch in about 1-3 minutes, if the stomach is producing too much stomach acid, belching will occur quickly and frequently. A Heidelberg or Gastrocap test can be used to confirm this initial simple test. Other tests, such as testing saliva samples for VEGF (vascular endothelial growth factor), the main regulator for tight cell membrane junctions in stomach parietal cells, which is directly proportional to the amount of stomach acid. Hypochlorydia may be indicated when salivary VEGF is too low. In the near future, labs that test saliva for various metabolites may add this test to their array of tests, but only if it is demanded.

The Issue of Dysfunction in Transient Lower Esophageal Relaxations and the appropriate treatment protocol

In recent years it has been discovered that a significant number of patients that complain of heartburn and reflux, especially of an episodic or transient nature, suffer from a condition called abnormal transient lower esophageal sphinctre relaxations. These relaxations of the entry into the upper stomach allow stomach acids to travel up into the esophagus when this neurohormonal reflex becomes dysfunctional. This condition may eventually cause GERD. Studies in Great Britain, Taiwan and Australia have confirmed that mild electrical stimulation at just one key acupuncture point (P6), will reduce the frequency of these transient lower esophageal sphincter relaxations by nearly 50 percent. Other studies have demonstrated that mild electrical stimulation at just one point (ST36) will significantly regulate intestinal motility, and presumably, other neural mediated intestinal functions. Research has demonstrated that these effects occur via the autonomic nervous system and enteric plexus. This is just one important protocol that can be utilized by an evidence-based Licensed Acupuncturist and herbalist. A thorough treatment protocol with herbs and nutrient medicines to promote gastric homeostasis, or normal physiological function, clear imbalances in the symbiotic microbial colony, such as heliobacter pylori or candida species, or to address other contributing factors to poor stomach health and function, will greatly help to restore the stomach and small intestine health. Holistic protocol will allow the patient to continue in life without dependency on treatment, reduce the risk of stomach and intestinal cancers, and provide for a better quality of life.

Modern medicine has recognized the prevalence of transient lower esophageal sphincter relaxations and gastric hypofunction, but pharmaceutical treatment has presented a quandary for prescribing doctors. The drug metoclopramide (Reglan et al) was first recognized in 1964, but was rarely prescribed except in cases of acute nausea and vomiting, due to the neurological side effects from prolonged use. The FDA approved metoclopramide only for short term use of 4-12 weeks for this reason, as metoclopramide works by binding to dopamine type 2 receptors to inhibit dopamine effects, and antagonizing effects at the 5HT3 receptors while increasing effects at the 5HT4 receptors, which affects the brain, or central nervous system, as well as the gastrointestinal mesentery. This neurological blocking stopped the brain from stimulating a vomiting reflex, but over time created other neurological problems, creating guidelines that only approved short term use. The drug was useful in acute crises, but not appropriate to treat the chronic condition.

Over time, though, drug manufacturers showed that metoclopramide and similar drugs could also treat gastric hypofunction, transient lower esophageal sphincter relaxations, motion sickness, GERD, and even migraines, and pushed for expanded use and sales. Unfortunately, prolonged use came with a very significant risk of developing a neurological condition called tardive dyskinesia and dystonia, or unwanted repetitive movements, and extrapyramidal effects as well. The list of neurological side effects range from mild manifestations that are often overlooked and ignored, such as nocturnal bruxism (teeth grinding and clenching), restless leg syndrome, anxiety, attention deficit and hyperactivity disorder, idiopathic tremors, unwanted eye movements and facial tics, to more serious problems such as Parkinsonism, seizures, depression, and neurolepsy. The term tardive implies that these symptoms develop gradually and with much delay, making the connection between the drug use and the onset of symptoms unclear.

With the occurrence of a large number of lawsuits when these neurological problems were diagnosed as having been caused by metoclopramide, studies showed that most patients now took the drug for longer than 12 months, rather than the approved 4 weeks. Since the drug is now generic, the Supreme Court has been faced with two cases where generic manufacturers are attempting to exclude themselves from liability, claiming that they are not as scientific as the standard drug companies and cannot be blamed for inadequate or misleading label warnings. In other words, the drug industry is attempting to lay full responsibility on the patient to choose wisely when using drugs that were highly restricted in use, but now are easily available without a prescription, or guidance by a medical doctor, and are highly likely to cause neurological problems when taken for a prolonged period of time. The ability to now purchase metoclopramide without prescription under a large number of names makes this drug a significant threat to health, and underscores the problems the patients and consumers now face in the drug market. To see the alarm that overuse of metroclopramide is finally generating, click here for a 2014 recommendation printed in the medical journal Critical Care that notes the neurological risk and other adverse effects: http://www.ncbi.nlm.nih.gov/pubmed/25672546 . While these experts recommended that we not entirely ban the drug for use in the intensive care units, where it is now regularly used due to deficient stomach acid production, we can clearly see the evidence of harm with chronic use. Studies of numerous adverse health effects from such misuse of a now generic over-the-counter drug are mounting, with not only dystonia, but asystolic cardiac arrest, facial tics (myoclonus), and other adverse effects linked, as well as the common adverse CNS effects of fatigue, mood fluctuation and dizziness. Studies have also shown that the risk of mild fetal deformities is a concern with use during pregnancy.

Surely, trying a safer and more conservative approach to gastric hypofunction and reflux, with electroacupuncture and herbal and nutrient medicine, which is now proven to work in human clinical trials, should be encouraged in standard medicine and popular with patients, yet it is not. The reluctance to integrate Complementary Medicine, when it is proven to work in human clinical trials and laboratory settings, by modern medical doctors in the United States, is slowly being seen by patients as a failure of our medical system that is prompted by a culture of economic interests over patient health. Patients are turning more and more to drugstore herbal remedies as advertising increases, yet the sensible use of professional Complementary Medicine in this area is still slow to take hold. Hopefully, this article will provide some insight into these widespread problems of gastrointestinal dysfunction and reflux, and prompt patients to take a more proactive and informed approach to acid reflux and reflux of gastric dysfunction.