Heartburn (GERD)

Heartburn is so called because your esophagus runs right past your heart (to the midline of course), and that’s where the pain is.  It’s a burning sensation and tends to be worse at night (when you’re lying down).  It has a sour or bitter taste, sometimes a sore throat and a chronic cough, and occasionally it can be associated with asthma.

Usually it can be diagnosed from clinical history, but there are a few other diagnostic measures – imaging mostly – which can potentially determine whether there is a structural cause (such as a narrow stomach opening – called pyloric stenosis – or stomach protrusion through the diaphragm – called a hiatal hernia).  But once structural causes are ruled out, other accepted causes include spicy or acidic foods (such as coffee, tea, orange juice or citrus in general, milk, alcohol, or nicotine), high stomach acid, or anything that might cause upward pressure, such as pregnancy or plain old extra weight.

Naturopathic docs will add a few more causes to that list.  Notably these causes include food allergies, imbalance of gut flora, and even too little stomach acid (hypochlorhydria).

The opening between the esophagus and the stomach (lower esophageal sphincter) is pH sensitive, and the acidity of the stomach causes it to close.  Too little stomach acid can prevent the sphincter from closing, which means it’s wide open so that the acid that is present in the stomach is free to splash back up into the esophagus – causing heartburn.  So while acid blockers may improve the symptom (less acid left to enter the esophagus in the first place), if this is the cause it won’t deal with the problem, and may even make it worse.

• Not surprisingly, antacids (aluminum-based, magnesium-based, and calcium carbonate-based) cause other gut disturbances, such as constipation, diarrhea, belching, bloating, and flatulence.  This makes sense, since the acid in your stomach is one of several steps to breaking down your food properly – and food that has not been broken down properly will end up being fermented by the bacteria in your gut.

• H2 Blockers (Zantac, Tagamet, Axid) block around 70% of acid production.  Because acid is necessary to protect against ingested bacteria, it can lead to increased risk of infection (gastroenteritis).
• Proton Pump Inhibitors (PPIs, such as Nexium or Prilosec) block up to 99% stomach acid secretion, and in addition to the above, they can lead to abdominal pain, diarrhea, and malabsorption (again, not surprisingly, since they are inhibiting a step in digestion), atrophy of the stomach lining itself (atrophic gastritis, which can predispose to gastric cancer), and by extension they can cause bone loss (due to lack of calcium absorption) and anemia (due to lack of Vitamin B12 absorption).

Just a note of caution: make sure if you decide to change or stop medications of any kind, you consult your doctor first.  Some of these need to be tapered and should not be stopped abruptly.

I am assuming that the workup for any structural causes has been done.  If all is negative, then…

• We find and eliminate the food sensitivity (and it may or may not be one of the triggers listed above.  Quite often it is not).
• If extra weight is a contributing factor, then weight loss is in order too, of course.

• Meanwhile we soothe the esophagus, repopulate the gut, and encourage acid production.  (Yes, you read that right.)

• Eventually we’ll taper off the meds, and if you’ve been on them for awhile we’ll address any deficiencies that may have resulted from their use.