What Really Causes GERD (Gastroesophageal Reflux Disease) and How Should It Be Treated?

by Ram

Damage by Melina Meza

GERD (gastroesophageal reflux disease) is a digestive disorder characterized by recurrent reflux of acid from the stomach into the esophagus triggering heartburn or acid indigestion. The esophagus is a muscular, tube-like structure that connects the throat to the stomach, which is lined by a moist, pink, gel-like tissue called mucosa. The food that you eat moves from your throat down to the esophagus. Two valve-like muscular structures exist in the esophagus to regulate the flow of the nutrients to the correct destination (from the esophagus to stomach to the small intestine). The upper esophageal sphincter (UES) at the top of the esophagus prevents food and other secretions from entering the windpipe by opening or closing at the appropriate time. The lower esophageal sphincter (LES) present at the esophagus-stomach junction prevents the stomach acids from traveling into the esophagus through its appropriate open-close function. 

Gastroesophageal refers to the stomach and esophagus. Reflux means return or flow back. Thus, gastroesophageal reflux is the reverse flow of stomach acids back up into the esophagus, either due to weakening of the lower esophageal sphincter muscles or due to inappropriate closure of the lower esophageal sphincter valve. Certain foods, fermented or fizz drinks, acidic fruits, cigarette smoke, and chronic stress can all cause the lower esophageal sphincter valve to relax, resulting in acid reflux into the esophagus. If this situation happens as a one-time event or acutely it is termed as a heartburn/acid reflux. If it is long lasting and a more serious form or a chronic issue, it is termed as gastroesophageal reflux disease (GERD).  

The most common symptom of gastroesophageal reflux disease (GERD) is heartburn. If the condition persists, additional symptoms may also appear, including a sour taste in mouth, chest pain, difficulty swallowing, dry cough, sore throat, and spewing of sour solids or liquids. Most people can manage the discomfort of GERD with lifestyle changes and over-the-counter medications. Over-the-counter treatments that may help control heartburn include:

1. Antacids that neutralize stomach acid
2. Acid production blockers, also called as H-2-receptor blockers, which provide longer relief and may decrease acid production from the stomach for up to 12 hours
3. Proton pump inhibitors, which are even stronger than H-2-receptor blockers of acid production

However, prolonged use of any of the above-mentioned medications can produce side effects, such as diarrhea, constipation, fatigue, confusion, or bone loss. If the heartburn and other symptoms don’t improve with lifestyle changes and medications, surgery may be the ultimate option. And while the symptoms of the heartburn may temporarily cease through the use of the above-mentioned medications, blocking the acid production is not a good remedy. There is a reason for the presence of acid in the stomach: it is necessary for proper digestion of food. The enzymes that digest the food completely work efficiently in the acidic environment. It is this combination of the acid and the enzymes in the stomach that facilitate efficient digestion of food to a form that can be easily delivered to the small intestine for further digestion and absorption. While the strength of the stomach acid is strong enough to burn a hole through a piece of wood, the stomach itself is well protected from its own acids. However, unlike the stomach, the esophagus does not possess any protective inner lining, resulting in its damage by the acids that shows up as a burning heartburn. This has been the premise so far. 

But now a new research study is changing this long-held paradigm (see Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes). According to this new study, the stomach acid backing up into the esophagus does not cause chemical burns and damage to the lining of the esophagus as thought earlier. Instead, the researchers from UT Southwestern-Dallas VA hospital suggest that the damage in patients with GERD actually occurs owing to an inflammatory response prompted by the secretion of inflammatory proteins called cytokines. The research work done in mice demonstrates that it takes several weeks for the stomach acid to initiate any damage in the esophagus. So it is unlikely that acids are the cause of the chemical burn since burns develop immediately. In follow-up studies on humans, the researchers followed 12 patients who suffered from chronic GERD. The patients who were taking proton pump inhibitors to control the acid reflux were asked to stop taking the medication. The researchers thought that GERD might redevelop if the medication were to be stopped, providing an opportunity to observe the early changes of GERD. Nearly all of the patients showed damages to the esophagus after stopping the medications. More importantly, the damages that reoccurred were not consistent with acid-triggered burns. Rather, the changes revealed all the tell-tale signs of an inflammatory response, suggesting that the stomach acid in the esophagus actually triggered a pro-inflammatory response by stimulating the production of small molecules called cytokines that trigger’s the body’s own defense system to go awry (see Chronic Inflammation and Yoga: Combating the Fiery Killer).

So what’s in this for the doctors and pharmacists? Since the study challenges a long-held belief about the role of the acid in damaging the esophagus, it is important for medical personnel to have the correct understanding of the mechanisms underlying GERD in order to facilitate novel GERD in order to facilitate novel GERD treatments. 

And what does it mean for people who have the condition and are desperate to jump off the antacid/PPI bandwagon? Good eating habits and good lifestyle practices that include a regular yoga practice go a long way in strengthening the gut. A balanced yoga practice includes asanas, resting poses, pranayama and meditation, all of which support the best possible digestion via our conscious mind and the autonomic nervous system (see The Digestion System and Yoga). As I mentioned in the beginning, chronic stress—which can over-activate the sympathetic nervous system (your Fight or Flight response)—is the single most common trigger of GERD (Our Hyper-Competitive, Stressful World), so consider meditation and restorative yoga practices when you know you are under lots of stress (see How to Practice If You Have Digestive Problems). All of the above practices together with healthy food choices and timely meals will promote a healthy digestion that is required to maintain a long health-span (Why You Should Care About Your Digestive System). So one alternative to consider working your way to healthy aging is by closely listening to your gut!

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