Integrative Approaches To Gastroesophageal Reflux Disorder (GERD)
As a Naturopathic Physician who has a special interest in gastrointestinal disorders, I am often approached to discuss something that effects so many people; GERD. I wanted to share with you an integrative approach that seems to help many people deal with this troubling problem. If you know me, I don't like to discuss treatment until I discuss the background of what we are dealing with . It might be a little heavy, but I think its important to share.
Gastroesophageal Reflux Disease background
Gastroesophageal reflux is a physiological process by which the gastric contents move retrogradely from the stomach to the esophagus. Reflux itself happens normally multiple times per day without causing damage or producing symptoms. However Gastroesophageal Reflux Disease (GERD) is when this process causes heartburn(pyrosis) and acid regurgitation. It is a disease that has a spectrum of presentations.
GERD is a very common problem. Over 50% of Hispanics experience heartburn at least monthly compared to 37% of Caucasians, 31% of African Americans, and 20% of Asians, according to a study of 1172 subjects. The severity of these subjects are unknown, some studies have been performed to actually determine how many GERD subjects actually have esophagus inflammation (esophagitis) and erosive esophagitis was found in 155 of 961 subjects (about 16%). It was noted that there was a bias in screening symptomatic patients. (Richter & Friedenberg, 2016). There are two major subsets of the condition called Erosive and Non erosive esophagitis (NERD).
Most patients diagnosed with GERD) are advised to take proton pump inhibitors and/or H2 blockers . And also have been told some general dietary advice to live with. They have been told that they will likely not need any further treatments and then to periodically get follow-up visits to decide whether endoscopy monitoring is necessary. This is something that seems to be on the surface a very reasonable and practical management style. However there are some questions about the long term use of proton pump inhibitors use being associated with conditions such as osteoporosis and most recently Alzheimer’s Disease or early dementia. So a seemingly benign simple treatment is now possibly contributing to other conditions. Please realize association does not mean causation but we have to take note.
So let’s talk briefly about the clinical findings in history and physical exam with gastroesophageal reflux disorder . Patients are likely to experience a gradual onset of gastrointestinal discomfort that is above the navel and possibly experienced as a burning sensation after meals or while on a full stomach. This burning sensation will be felt in the sternal region and will be described as traveling from the base of the sternum upwards towards the mid chest region.
Patients will also complain of regurgitation (burping up) up stomach contents. (Bredennoord, Pandolfino, & Smout, 2013). Again the symptoms will be described as worse after meals and also worse in the lying down position many patients will describe this as bothersome irritating troublesome and will be waking them sometimes in the middle of the night leading to sleep disruption. General physical exam will not reveal any particular physical exam findings. So this condition is largely based on the patient’s description of the symptoms.
The anatomical explanation of GERD points to a dysfunction in the esophagogastric junction which is made up of 3 components then lower esophageal sphincter, the crural diaphragm, and the anatomic flap valve. This 3-part complex functions as the anti-reflux barrier. (Bredennoord, Pandolfino, & Smout, 2013). The barrier breaks down when the lower esophageal sphincter is overwhelmed by increased intra-abdominal pressure usually after meals.
Neurologically speaking the most common mechanism for reflex is transient lower esophageal sphincter reactions (TLOSR’s) which are independent of swallowing. These are triggered by a vagal nerve mediated reflex that is triggered by gastric distention and serves to enable gas venting from the stomach. In GERD, the TLOSR can persist for 20 seconds which is much longer than typical esophageal relaxation. During TLOSR’s the right crura of the diaphragm which is an additional sphincter(external) for the esophagus will temporarily stop functioning again further reducing the protection of the stomach contents from the esophagus. (Bredennoord, Pandolfino, & Smout, 2013)
In addition the flap valve at the end of the esophagus can become noticeably weaker (as seen on endoscopy).
For reflux to take place, the proximal stomach pressure must be greater than the pressure in the esophagus (termed increased intragastric pressure). Activities that lead to amplified pressure in the stomach like straining and coughing can change this gradient. Chronically increased pressure gradient can occur during pregnancy and in overweight or obese people.
Other risk factors for GERD
Esophagus body dysfunction.
Prolonged acid clearance happens in conditions like hiatal hernia and failed peristalsis.
Delayed gastric emptying. There seems to be an association with delayed gastric emptying in reflux disorders.
Acid pocket: After meals a layered unbuffered acid gastric juice sits on top of the meal close to the cardia, ready to reflux. This is known as the “acid pocket” and is facilitated by the absence of peristalsis (movement) in the proximal (upper) stomach. In patients with GERD this pocket is located
The cause for GERD is generally thought to be due to a laxity or weakening of the lower esophageal sphincter that separates the gastric contents from the esophageal contents. Hence, the gastric contents are not being sealed off from the esophagus and a sensation is felt in the chest from actual stomach acid being expressed along tissue that is not designed to tolerate this substance. This is the predominant theory known to clinicians and researchers.
Clinical manifestations of the disease
Most reflux symptoms can be managed without any significant monitoring or therapeutic intervention. Some people will find that their symptoms will resolve with lifestyle changes and weight loss. In a subset of patients , we are concerned that the reflux disease will lead to chronic irritation of the mucosa of the esophagus . Which, in some scenarios, can lead to dysplastic changes of the esophagus and eventually can progress to a condition called Barrett’s esophagus which is a risk for esophageal cancer.
The risk of esophageal cancer in patients with Barrett’s esophagus is approximately 0.5 percent per year (or 1 out of 200). If initial biopsies don’t show dysplasia, endoscopy with biopsy should be repeated about every 3 years. If your biopsy shows dysplasia, more aggressive monitoring and treatment is employed.
Some patients will remain on palliative treatments for many years without any routine endoscopy as it is determined that the acid blocking medication is maintaining good control of the disease.
Its important to know that extra-intestinal symptoms of hoarseness, cough, and asthma can develop from GER(D). (Bredennoord, Pandolfino, & Smout, 2013)
While reflux disorder can mimic other conditions the most concerning would be a cardiovascular pain such as angina or cardiovascular disease. An abrupt onset of this type of pain course is suspicious of myocardial infarction. Chronic sternal pain however mimics only a few conditions such as chronic musculoskeletal pain. Also a condition called dyspepsia which is indigestion without the esophageal sphincter involvement can also be considered . Of course any type of digestive pain symptoms with nausea and weight loss may mean a serious digestive disorder like digestive related cancer.
In the gastroenterology office most patients are put on a therapeutic trial of proton pump inhibitors or H2 blockers to see if they will control symptoms. A therapeutic trial of these medications, is a diagnostic test that can confirm the diagnosis of GERD if your symptoms disappear with a PPI or H2 blocker.
If the patient’s symptoms are controlled with these medicines there usually is no need for endoscopy. Other patients who don’t maintain control of these symptoms with the therapeutic trial might be put through on endoscopy to determine if there are other causes for reflux disorder.
Alarm symptoms of reflux with painful swallowing(dysphagia), coughing up blood (hematemesis), and weight loss warrant an upper GI endoscopy. (Bredennoord, Pandolfino, & Smout, 2013)
Very few patients with GERD will progress to more concerning conditions like esophageal cancer due to Barrett’s esophagus. Most will be due dealing with some sub clinical version of reflux throughout their life after this has begun. The most dedicated patients will find a way to work on underlying causes such as stress ,diet, and lifestyle and potentially reverse their symptoms. Without effort, it is the experience of this author that they will not likely improve.
Conventionally patients are typically put on proton pump inhibitors such as omeprazole or H2 blockers such as ranitidine and these are usually twice daily dosing. Upon discontinuation, these medications are generally tapered off or tapered down as they cannot be abruptly stopped. Occasionally additional medications might be used such as over-the-counter acid buffering medications such as “Tums” and a new category of medications now is being used that acts on the top layer of the gastrin to reduce gas in that region (alginates).
Patients are generally told to stay away from food triggers that will increase the likelihood of laxity of the lower esophageal sphincter. These include reduction of alcohol, tobacco, coffee, caffeine, chocolate, fried foods, dairy, citrus fruits and certain herbs like mint.
One study recently showed that the frequency of fast food consumption is associated with reflux. In my informal poll, of my GERD patients I can assure you fast food doesn't help the cause.
Patients are generally told that overeating is likely to contribute to their symptoms and to allow for 2 to 3 hours of upright positions after eating prior to going to bed. Patients are generally encouraged to normalize their body weight or lose any weight that has been gained leading to the onset of the symptoms. Some subsets of patients might be also told to work on stress management.
Naturopathic and Functional Medicine Approaches
Because of the concern of the use of conventional medications, numerous natural therapeutics have been employed to help balance many digestive disorders including GERD.
Along with the dietary changes and lifestyle changes, meditative techniques have been demonstrated to control the patient’s reflux disorder at some equivalents to medications.
A protocol for GERD breathing exercises can be found here and here . It is likely that the breathing exercises are working on the limbic system and likely improving the tone of the vagus nerve stronger and therefore shortening TLOR time.
General dietary suggestions if you have been diagnosed with GERD:
Avoid greasy, fatty food in excess.
Avoid spicy, tomato based foods in excess.
Avoid mint, chocolate, and coffee in excess.
Avoid tight waistline pants.
Space meals 3-4 hours apart. Avoid grazing.
Chew food mindfully and slowly.
Avoid eating after 8 pm when possible.
Herbal and Nutritional Supplementation:
Deglycyrrhizinated liquorice (DGL)
This is a derivative of the plant Glychrriza glabra root (Licorice root). Patients may find that taking 400 mg (chewing) of this with or before each meal will help control reflux. Also this again be taken at bedtime to prevent. DGL is thought to possibly help with mucus secretion in the stomach. Please note DGL does not raise blood pressure whereas Licorice root that has not been deglycrrhizinated might raise blood pressure.
Slippery Elm Powder
This is another herbal medicine that mechanism of action is to increase mucin production in the stomach which helps with maintaining proper pH balance thereby helping control the esophageal sphincter. Generally speaking anywhere from 1000 to 2000 mg of Slippery Elm Powder is taken with meals to help with control of symptoms.
This is an amino acid that helps with repairing the lining of the stomach and small intestine and generally helps decrease inflammation and irritation to the stomach. It’s mechanism in the GERD patient may be attributed to this. Generally speaking patients will take 1000-2000 mg of L-glutamine with each meal. Some patients who are sensitive to it may react with hyperactivity so this must be monitored.
A terpene from several citrus plants; D-limonene has several gastric acid neutralizing properties and also regulates peristalsis. This is a remedy has been proven to help with reflux disorders . In addition it may help the gallbladder with its innate function of digesting fat.
Ulmus/Althea (root): add 4 Tablespoons to 1 Liter room temperature water(step overnight) strain to press in the a.m. Add 2 tsp L-glutamine powder mix thoroughly and drink throughout the day for demulcent properties/anti-inflammatory properties. This is an old naturopathic remedy for GERD.
If not responding to treatment:
Other treatments that might be provided for the patient is digestive enzymes and probiotics to help with the overall function of the upper intestine and digestive process.
It is not uncommon that patients are deficient in digestive enzymes and upper intestine probiotics such as Lactobacilli spp. There is a subset of patients that seem to have low hydrocholoric acid (HCl) instead of high hydrochloric acid (HCL) . This is a controversial discussion in reflux disorder. Usually HCl should only be used in the GERD patient who fails these other therapies.
Preventing GERD is largely seen by focusing on healthy weight management and healthy stress management. Abrupt changes in weight and abrupt overheating patterns can bring on this condition.
Experience and meaning
it is easy for the practitioner to treat GERD as a minor issue. However for the patient suffering from GERD this can severely impact their quality of life. Including, socializing dining, sleeping, and an overall sense of well-being. They often are constantly clearing their throat and may be seen as unwell by others even though their immune system is perfectly healthy. The pain and discomfort can be intolerable to some subsets of current patients.
In my practice I recommend all patients with non-resolving GERD get screened for H. Pylori and Small Intestinal Bacterial Overgrowth, Fungal Overgrowth and for specific food intolerances.
I also recommend being screened for an anxiety disorder.Understanding the underlying cause of GERD, helps design appropriate treatment. There are many other options to explore besides proton pump inhibitors and H2 blockers.. Having someone guide you through this process will help insure your successful management. Its important you also are supported by a team of practitioners that would know when to refer you in for an upper endoscopy or for other lines of investigation if not responding to treatment.
If you have found anything particular helpful your GERD please email me at firstname.lastname@example.org