Food That Doesn't Go Down May Come Up
Section titled “Food That Doesn't Go Down May Come Up”A 40-year-old woman I'll call Jessica sat in my office and described a bloating in her stomach and a burning in the middle of her chest. A tidy-looking woman, thoughtful and in control, she had monitored her symptoms for several months and tried to manage them on her own. Antacids gave temporary relief but led to some constipation. Her friends suggested an over-the-counter medication such as omeprazole (Prilosec). She came to me hoping to find a more natural and long-lasting solution.
Jessica was displaying classic symptoms of heartburn, a condition that occurs more frequently than you might imagine. In the US, 60-70 million people suffer from digestive disorders every year. Antacids and other digestive remedies line the shelves of drugstores and grocery stores for the bilious millions.
There are times when pharmaceuticals beat out the natural remedies. In this situation, however, patients usually benefit from paying attention to their digestion rather than opting for fast, fast, fast relief by suppressing their symptoms with over-the-counter meds.
What Causes Heartburn?
In many patients like Jessica, symptoms are due to malfunctioning lower in the gastrointestinal tract. Let's look at the possibilities.
Lingering Stomach Contents Can Raise Trouble
At the top of the stomach, in the diaphragmatic opening between the abdomen and the chest, sits a potentially leaky valve, the gastro-esophageal junction. This transition from the acid-sensitive esophageal lining to the tough, corrugated, acid-resistant stomach lining is loosely collared by the relatively thin muscle of the diaphragm.
The powerful acids and enzymes in the healthy stomach transform meat into a liquid in less than an hour. Usually, half our food has passed through our stomach in fifty minutes. However, the stomach doesn't always empty as quickly as it should. It takes over two hours, on average, in an older person1. At a younger age, diabetes and other medical conditions can impair emptying of the stomach. Even healthy younger people may experience delayed gastric emptying, and I suspected that was Jessica's problem.
The longer the stomach contents linger, the more likely that we are going to squeeze some of it back up through the gastro-esophageal junction into our esophagus, producing acid heartburn or – if chronic – gastrointestinal reflux disease (GERD).
Symptoms and Situations
If a person has a bit of a spare tire, and he bends forward after a meal, the increased abdominal pressure often suffices to push stomach contents up into the esophagus. Likewise, lying down on a full stomach, excess activity, and stress can trigger heartburn. Those who have GERD figure most of this out on their own.
They experience burning or pain behind the sternum and sometimes stomach contents coming up into the back of the mouth (this is called "waterbrash"). Often, however, they aren't even aware of the reflux. They go to their doctor with hoarseness or a chronic cough, only to learn that this may result from GERD. Their doctor gives them a therapeutic trial of an acid-suppressant, and the cough or hoarseness disappears.
Conventional Medical Approaches
When Jessica experienced heartburn, she found temporary relief from antacids. She asked me why that worked. I explained that her stomach lining could resist a highly acidic environment, but her esophagus was very sensitive. Lowering the acid in the stomach allowed her to bring up a less-acid or neutralized material into the esophagus, which she could not feel. Regular exposure to acid not only makes the esophagus uncomfortable, it erodes the tissue and can lead to serious disease. If over-the-counter antacids don't help, most doctors treat chronic heartburn with proton-pump inhibitors (PPI's) such as omeprazole to inhibit the production of stomach acid. Many people also find relief from the older drugs such as cimetidine or ranitidine (a histamine-blocker), which also suppress acid production.
Traditional and Naturopathic Approaches
I told Jessica that over three-quarters of our patients with GERD experience major improvement with attention to digestion. The goal is to reduce acid heartburn by enhancing digestion, so that the stomach contents make their journey downward in a timely fashion. Many indigenous medical systems, including Indian and Chinese schools, have long used digestive bitters or ginger, which increase stomach secretions and stimulate digestion. US naturopaths use betaine hydrochloride, an encapsulated powder, which supplements our own hydrochloric acid when the capsule dissolves in the stomach. Midway between these two measures in potency are products that combine low dose betaine hydrochloride, pancreatic enzymes, and bile salts.
Why do these help? The bottom of the stomach massages our food and our stomach juice, grinding large pieces into small, and then into a liquid we call chyme. The bentaine hydrochloride helps this break-down. Then the chyme is squirted, bit by bit, through the pyloric valve into the duodenum, where it is alkalinized and further processed by the biliary system and pancreas. The pyloric valve will wait till the bile and pancreatic enzymes have done their work on the first bit before releasing any more chime. When the downstream digestion flags, our lunch loiters in the stomach. Taking supplementary pancreatic enzymes and bile salts helps this process along.
Jessica opted to give the combination product a therapeutic trial and, within a few days, had no symptoms. After a few months, she discontinued the combination product. She felt well for many months. Now, when the symptoms return, which is rarely, she takes the digestive enzymes for a few days, and the heartburn goes away.
The standard medical disclaimer for articles of this type is, "Don't try this at home, folks!" I won't go that far, but let me give you one caveat. Most of the digestive "enzymes" on the store shelves lack oomph. Most of those advertised throw around the right words, but lack substance. If you want to try this, use a proper preparation, such as Thorne's Biogest. And these will not work in combination with antacids.
Potato in the Tail Pipe Theory
Another angle on heartburn -- a controversial and unproven theory -- can be summarized this way: what doesn't go down, must come up. Ayurvedic (from India) medicine teaches that, for some people, constipation results in acid reflux.
Downstream blockage is felt all the way up. We can be like a car with a potato up the exhaust pipe. If the tail pipe is blocked, the engine sputters.
When the colon backs up, many people are not aware of the fact. They come in with heartburn or a stomach ache, lie down on my examining table, and I can palpate significant excess stool in their lower abdomen. Sometimes a strong laxative to get the colon moving will relieve the downstream blockage and stop the GERD. In that case, a fiber supplement to keep things moving will maintain the improvement. We discussed healthy bowel options in our January 2008 newsletter, which contains more resources and options.
Again, nothing works all the time, but if this is the answer for you, we sure want to know about it.
A Note about Hiatal Hernias
Many times people tell me that they have a hiatal hernia in a tone of resignation, as if they are now doomed to have heartburn the rest of their lives. A hiatal hernia is a protrusion of a small part of the stomach through the thin muscle of the diaphragm. Hiatal hernia occurs in about 10 percent of young people and in about 70 percent of those over 70 years of age2.
Hiatal hernia poses a challenge to your digestion, but you cannot assume that it is the sole cause of your GERD. Gastrointestinal reflux disease, or GERD, does not occur in every individual with a hiatal hernia. About a third of Americans will experience GERD at some point in their lifetime3, while perhaps half as many develop a hiatal hernia. Anatomic variation does not make disease. Digestion is the dynamic function of the living organism, body and mind.
Why Go To All This Trouble?
Why tinker with fiber and supplements? Why not just reach for the antacids or the "purple pill" once a day? Because, in the long run, you are better off with proper digestion. PPIs may bring relief, but they are not without problems.
* They increase the risk of hip fracture4.
* They double the risk of Clostridium difficile colitis5.
* They increase the risk of B12 deficiency, because unique among vitamins, we require stomach acid to absorb it6. B12 deficiency increases the risk of Alzheimer's dementia and other neurodegenerative conditions7.
* Some evidence points to an increased risk of gastro-esophageal cancer with long-term use of PPI's, though the mechanism is unclear8.
* Decreased stomach acid impairs downstream absorption of nutrients, which decreases with age anyway. As we age, our intestine requires more vitamin D in order to absorb calcium and maintain strong bones, so let's keep our digestion strong9.
That said, improving digestion doesn't always eliminate acid reflux. Some people have such an irritated esophagus that stopping the PPI for even a day leads to intolerable symptoms, and efforts to improve stomach function just don't have time to work. Sometimes, we can get them over the hump by starting with a combination of slippery elm and medicinal licorice. Other times, both the patient and I throw up our hands and decide to be happy that PPI's provide blessed relief.
Summary and Cautions
Impaired digestion occurs much more commonly than we realize. GERD is just one symptom; constipation, laryngitis, and cough can be others. Fatigue, especially in the elderly, sometimes arises from vitamin B12 deficiency linked to impaired digestion.
It is better to improve digestion than to mask the symptoms with PPI's. This is especially important as we age and our digestion slows down. Your digestion is uniquely your own, and there are too many considerations to cover them all in this newsletter. I recommend educating yourself and working with your health care provider on the long-term project of good digestion.
You can read more about GERD on Wikipedia.
Monroe Street Clinic News – New Email Service
Section titled “Monroe Street Clinic News – New Email Service”In response to numerous requests, you may now email Dr. Rienstra with simple questions. We want to try out this new way of providing quick answers to simple questions without an office visit. Our fee for this service during our initial test period will be $29 per email question and response. After we get the bugs out, on May 1, this fee will rise to $39. You will also have the option of proposing your own fee.
Footnotes
1: Am J C/in Nuir l992;55:1203S-7S. "Changes in gastrointestinal function attributed to aging."
2: http://emedicine.medscape.com/article/178393-overview "Hiatal hernias are more common in Western countries. The frequency of hiatus hernia increases with age, from 10% in patients younger than 40 years to 70% in patients older than 70 years."
3: http://www.aafp.org/afp/990301ap/1161.html "Gastroesophageal reflux disease (GERD) is a chronic, relapsing condition with associated morbidity and an adverse impact on quality of life. The disease is common, with an estimated lifetime prevalence of 25 to 35 percent in the U.S. population."
4: JAMA 2006 Dec 27;296(24):2947-53.
5: N Engl J Med 2008;359:1700-7.
6: Am J Clin Nutr 1992 55: 1203S-1207S. "Changes in gastrointestinal function attributed to aging" Boston researchers measured stomach acid in people over the age of 80. Forty percent of them had atrophic gastritis, meaning that their stomachs produced much less acid and pepsin and could not absorb vitamin B12.
7: Acta Med Scand 1969, 186:529 B12 deficiency occurs more often in people with hypothyroidism, as does impaired production of stomach acid. We don't know which causes which, but further reduction of stomach acid with a PPI isn't something to do lightly.
8: Gut 2006 Nov;55(11):1538-44. "Long term pharmacological gastric acid suppression is a marker of increased risk of oesophageal and gastric adenocarcinoma. However, these associations are most likely explained by the underlying treatment indication being a risk factor for the cancer rather than an independent harmful effect of these agents per se."
9: Journal of Clinical Endocrinology and Metabolism 1992, 75:176.