Acid Reflux and GERD - An Overview
What is GERD?
Gastroesophageal reflux disease (GERD) is a chronic disorder characterised by the regurgitation of stomach contents (acid, pepsin or bile) into the oesophagus throat, mouth and even lungs. GERD is predicted to impact 13.98% of the adult population worldwide. In the UK, GERD affects up to 20% of the population.
What is the difference between acid reflux and GERD?
Acid reflux is the involuntary flow of stomach acid back into the esophagus due to a weakened lower esophageal sphincter (LES) pressure. When acid reflux occurs at least twice a week, this is termed as GERD (Gastresophageal reflux disease) where a dysfunction of the lower esophageal sphincter pressure allows the flow back of stomach acid into your esophagus, irritating its lining which eventually lead to inflammation.
How is GERD diagnosed?
In order to diagnose GERD, pHmetry is used, along with questionnaires, and sometimes PPIs, with the aim of assessing patients’ answers. To identify GERD complications, or evaluate the need of antireflux surgery, patients undergo an upper endoscopy.
What is lower esophageal sphincter?
The lower esophageal sphincter (LES) is made up of muscle at the bottom of the esophagus and surrounded by the diaphragm (also a muscle), that keep the sphincter tightly cLESed and separating the esophagus from the stomach, these two muscle layers prevent stomach contents from flowing upward (refluxing) into the esophagus.
What is the pathophysiology of GERD?
A weak or damaged lower esophageal sphincter is the main cause of GERD and other esophageal disorders. If a persons LOS is weak or damaged, the muscle can lose its ability to close (like GERD). When the LES fails to close, it allows stomach acid to flow up from the stomach into the esophagus, causing severe acid reflux and heartburn. Other mechanism thought to play a role are transient relaxation (reduced tone) of the lower oesophageal sphincter, increased intra-gastric pressure (for example straining and coughing), delayed gastric emptying, and impaired oesophageal clearance of acid.
What causes the LES pressure to weaken?
A disordered LES pressure leads to weakened LES pressure. LES function is controlled by the gastrointestinal smooth muscle and through the autonomic and enteric nervous systems. Under normal conditions, the LES remains contracted and relaxes to open and allow food to enter the stomach.
The physiologic factors controlling LES function are interrelated in a complex way. They include the autonomic nervous system, gastrointestinal hormones, and correct LES pressure. A defect in any of these three controlling mechanisms would result in various symptoms. Most of the causes of a weakened LES pressure mentioned below is preventable.
1. Hiatus Hernia
When the stomach is dislocated through the hiatus of the diaphragm into the chest, and the crural diaphragm becomes separated from the LES, this increases abdominal pressure and weakens LES pressure resulting in reflux. Hiatal hernia can be caused by being overweight, pregnancy, abdominal injury and Barretts esophagus.
2. Overeating or Being Overweight
When a person regularly overeats or is overweight, this causes stomach distention and puts a lot of extra pressure on the LES. Over time, the LES loses its shape and its strength, allowing acid to flow upward, causing further damage to the LES.
3. Pregnancy
Several mechanisms contribute to GERD symptoms in pregnancy, including decreased LES pressure, increased intra-abdominal pressure due to the enlarging uterus, and GI motility changes. Increased circulating levels of progesterone and estrogen during pregnancy increases LES relaxation and allows reflux.
4. Smoking
Smoking exposes the esophagus to a lot of toxins and chemicals that damage the membranes in the LES, causing it to weaken. In addition to this, smoking raises the acidity of stomach fluids which can impact the LES more strongly than regular stomach acid.
5. Drinking Alcohol
Alcohol is known to be a trigger for people with GERD as it relaxes the muscles in the LES and allows stomach acid to flow upward, which over time also causes considerable damage to the LES.
6. Certain Medications
There are several medications that can damage your LES by causing it to relax. If they are consumed regularly, the LES will remain relaxed and result in acid reflux, causing damage to the muscle and membranes. Blood pressure medication, hormone replacement therapy, sleeping pills and sedatives, antibiotics, antidepressants, iron and potassium supplements, and proton pump inhibitors can weaken the LES.
7. Certain Foods
Trigger foods high in saturated fats, caffeine, chocolate, chilli, fizzy drinks and acidic foods are something people with GERD always have to avoid as it tend to cause the LES to relax.
8. Emotional Stress and Anxiety
The vagus nerve controls our digestive system such as stomach acid production, maintain LES pressure and gut motilty. When under extreme emotional stress or anxiety, these important functions are impaired leading GERD related symptoms. An increase in heartburn symptoms was found in a study of people who already suffer from heartburn when they were exposed to stress.
9. Type 2 Diabetes Mellitis
Acid reflux and GERD are shown to be associated with diabetic neuropathy - nerve damage due to persistent high blood sugar. Although nerve damage commonly occurs in the legs and feet, it can also occur in the vagus nerve. The vagus nerve regulates many parasympathetic functions in your body – functions that you cannot consciously control including digestion.
What are the symptoms of GERD?
The most common symptom of GERD is heartburn, a burning sensation in the chest area, caused by stomach acid refluxing into the oesophagus and radiating toward the mouth. The burning sensation in the chest area that may radiate to the neck or the back. Heartburn may worsen when lying down or bending over.
Other common non-exhaustive symptoms include:
Indigestion
Sore and inflamed throat
Regurgitation
Globus sensation
Difficulty swallowing
Recurrent cough
Throat clearing
Hoarseness
Bronchospasm
What are the complications of GERD?
Left untreated, GERD can result in several serious complications, including;
Eosophagitis (erosion and ulcerations)
Barrett’s esophagus
Difficulty swallowing
Iron deficiency or iron deficiency anemia
What are the treatments?
Western medicines approach is to prescribe Proton Pump Inhibitors (PPIs) and H2 Blockers to suppress the production of stomach acid, to eliminate trigger foods and implement lifestyle changes. Antacids are used to neutralise the acid in your stomach to relieve indigestion and heartburn. However, long term use of PPI suppressing low stomach acid or antacids neutralising stomach acid pH leads to nutrient deficiencies and small intestinal bacterial overgrowth. Rebound symptoms of increased stomach acid production often occurs when PPI medication is stopped without proper weaning off.
The naturopathic nutritional therapy approach is to address the underlying cause and risk factors to increase the integrity of the LES through nutrition and lifestyle medicine. At the same time, we naturally calm the symptoms of reflux to support the healing process.
References:
Clarrett DM, Hachem C. Gastresophageal Reflux Disease (GERD). Mo Med. 2018 May-Jun;115(3):214-218.
Lee, S. D., Keum, B., Chun, H. J., & Bak, Y. T. (2011). Gastroesophageal Reflux Disease in Type II Diabetes Mellitus With or Without Peripheral Neuropathy. Journal of neurogastroenterology and motility, 17(3), 274–278. https://doi.org/10.5056/jnm.2011.17.3.274
Rosen, R. D., & Winters, R. (2023). Physiology, Lower Esophageal Sphincter. In StatPearls. StatPearls Publishing.
Song, E. M., Jung, H. K., & Jung, J. M. (2013). The association between reflux esophagitis and psychosocial stress. Digestive diseases and sciences, 58(2), 471–477. https://doi.org/10.1007/s10620-012-2377-z