GERD, also known as gastric reflux, is a disease where the sphincter between the esophagus and stomach functions improperly and stomach acid is able to ‘reflux’ upwards into the esophagus. Most people assume that the underlying reason why they have reflux is simply due to an over-abundance of acid in their stomach. If your stomach is full of excess acid, it has to go somewhere, right? While the simple reasoning behind this assumption makes sense, this theory is actually inaccurate for most cases of GERD.
When looking for underlying root causes of GERD, the key is to focus on why the sphincter is ‘leaky’ in the first place. What can change the ability of that sphincter to work like it is supposed to? A lot of it comes down to the pressure gradient across that valve, which is the difference in pressure on one side verses the other. So now that we have that background information, let’s talk about what I see in my practice as a common root-cause reason why patients develop GERD: low digestive enzyme output.
When you begin eating a meal, this triggers the start of the complex physiological process known as digestion. This digestion process involves the simultaneous activity of many organs in GI tract, including the esophagus, stomach, liver/gallbladder, and intestines. The hormone gastrin stimulates more acid production directly in the stomach. Acid specifically helps with the breakdown of proteins, carbohydrates, and fat. At the same time, the pancreas releases a large variety of enzymes that help to breakdown of fats, proteins, and carbohydrates once the food has passed from the stomach into the first part of the small intestine. Nearby, the liver and gallbladder release bile which further assists with fat and protein digestion. When all these organs, hormones, and enzymes are working properly, we can quickly and thoroughly break down our food into small bits can then be absorbed further on down the tract. Absorption is the process of taking in micronutrients through the lining of the small intestinal tract for the body to then use and store, but we can only absorb these nutrients if the food has been broken down into small enough pieces.
When digestive enzyme output is low, the improperly digested food moves more slowly out of the stomach and through the intestinal tract than it would otherwise. This can lead to stagnation in the system, which then often causes an increase in gas production due to bacterial fermentation of undigested food. All of this improperly-digested food and air increase the pressure underneath that important esophageal sphincter, which can then cause the reflux symptoms that you feel. On top of that, low hydrochloric acid specifically can inhibit the normal pressure gradient across that valve all on its own, even if all the other enzymes are working properly.
The myth that most cases of GERD are caused by high stomach acid and not low stomach acid is perpetuated by the fact that acid-blocking medications WORK. At least they work in the sense that they almost always decrease reflux symptoms. So how come people with low-acid reflux still improve symptomatically when taking an antacid? Well, even people with low acid have some acid. So if we lower this acid level even further, there will be even less to reflux back up into the esophagus after meals—resulting in decreased symptoms. We didn’t fix the leaky valve, we just further reduced what can go back up through it when it leaks.
While this may seem like a “good enough” approach, long-term antacid use is associated with a huge number of potential negative side-effects. Most of these side-effects stem directly from people missing out on all the beneficial things that stomach acid does for us. Acid helps to kill bacteria that enter through our mouth, it ensures proper food breakdown, and allows for adequate absorption of nutrients from that food down the line. Some of the most common long-term effects of antacid medications are: increased risk of fractures due to osteoporosis, pneumonia, chronic low magnesium levels, C. difficile diarrhea, dementia, and B12 and other micronutrient deficiencies (1). Studies are also starting to show significantly increased risk of SIBO in patients taking antacid medications (2). See our blog article here for more information on this topic.
These long-term effects are so concerning that doctors are instructed by the drug manufacturers to only prescribe them for short term (1-2 week) usage. But without addressing any of the underlying causes of a patient’s GERD, symptoms will return as soon as the medication is discontinued. This is why many people continue to take heartburn medications for years and years with no way to come off of them.
Naturopathic physicians are trained to find and address underlying causes of disease. While low enzyme output is not the only cause or contributor to GERD, it is something that I always consider when treating patients with this condition. It is important to mention that many antacid medications cannot be discontinued cold-turkey without a significant reaction known as ‘rebound hyperacidity’. This acid reaction can be very painful and is also damaging to the esophageal tissue. Additionally, patients with underlying gastritis (stomach inflammation) will experience extreme discomfort and worsening of their condition if they experiment with acid-containing enzymes on their own. This is why it is important to work with the physician who is trained on how to properly evaluate and treat your condition if you suffer from chronic GERD. For more information on how we might be able to help you specifically, click here to schedule a free 15-minute consultation.
Dr. Katie Nuckolls is a naturopathic physician and owner of Thrive GI: Natural Digestive Medicine in Vancouver, Washington. She currently sees patients that live in Washington, Oregon, and Arizona using telemedicine. For more information, visit our contact page or schedule a free 15-minute consultation online.
- https://www.mayoclinicproceedings.org/article/S0025-6196(17)30841-8/fulltext#:~:text=Although%20PPIs%20have%20had%20an,chronic%20kidney%20disease%2C%20and%20dementia.
- https://www.gerdhelp.com/blog/references/increased-incidence-of-small-intestinal-bacterial-overgrowth-during-proton-pump-inhibitor-therapy/#:~:text=SIBO%20was%20detected%20in%2050,year%20of%20treatment%20with%20PPI.