What Really Causes Acid Reflux and GERD.docx
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What Really Causes Acid Reflux and GERD.docx
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WhatReallyCausesAcidRefluxandGERD
WhatReallyCausesAcidRefluxandGERD?
ThisisthefirstarticleofafourpartseriesonacidrefluxandGERD.Readthe secondarticle onthemythsofH.pyloriandlowstomachacidbeingthemajorcauses,the thirdarticle onthemainstreammedicaltreatmentsandthe finalarticle onthemythsoftriggerfoodsandaGERDdietthatworkswithoutdrugs.
WhatisAcidRefluxandGERD?
AboutsixtymillionpeopleintheUSreportthattheysufferfrompainfulsymptomsofacidrefluxatleastonceaweek.Heartburn,abdominalpain,cough,regurgitation,sourtasteinthemouth,sorethroat,hoarseness,laryngitis,asthma-likesymptomsandsinusirritationarethetypicalsymptoms.Smoking,pregnancy,obesity, hiatalhernia andeventight-fittingclothescanmakethesesymptomsworse.
Acidrefluxoccurswhenacidandothercontentsofthestomachescapeintotheesophagusandbeyond.Chronicacidrefluxisoftenassociatedwithdamagebecausetheesophagusandotheraffectedtissuesarenotprotectedbythethickmucuslayerthatcoatstheinsideofthestomach.And,theresultispainfulirritationwhichcanleadto esophagitis, and Barrett’sesophagus,even esophagealcancer.
Persistentdamagingrefluxisreferredtoasgastroesophagealrefluxdisease(GERD). Acidrefluxmayalsocausesevereirritationofthevocalcords,aconditionreferredtoaslaryngopharyngealreflux(LPR).
MyStory
Formethissubjectispersonal.Iamoneofthesixtymillionpeople.Isufferedwithacidrefluxforagoodpartofmyadultlife.Ineverunderstoodwhatcausedit.Ionlyknewthatmyconstantheartburnandregurgitationsymptomsinterferedwithmywork,mysleepandmygeneralwellbeing. Myconditioncontinuedtogetworseleadingtoanyone’snightmare.
Iawokeinthemiddleofthenightandleaptoutofbedstillhalfdreaming,thinking“Ohmygod,thisiswhatitfeelsliketodie.”Icouldn’tbreathe;Iwaschokingforairandmylungsfeltliketheywerefilledwithburningliquid.Irantothebathroomcoughingupsomethingfrommylungsthatsimplydidnotregister.Itfeltlikeacidwasfillingmylungs.IsoonrealizedthatIhadsufferedsevereacidreflux;stomachacidthattraveledupmyesophagusuntilIaspirateditintomylungs.Iwillneverforgetthatmoment. ItdefinedthekindoffearandsufferingthatispossiblewithGERD.
Likemanypeoplewiththiscondition,Irecognizedthatmysituationwasbecomingserious.Buttherecommendedmedicines–antacids,H2blockersandevenPPIdrugsdidnotgivemeadequatereliefandInevernoticedanydietarypatternthatimprovedmysymptoms.Butthatallchangedin2004.
Ontheadviceofmyolderson,apersonalfitnesstrainer,Idecidedtogoonalowcarb,highfatdiet(LCHFD)toloseafewpounds.Whathappenednextmademeforgetaboutweightloss,becausemyrefluxsymptomsvanishedtheverynextday.Icouldn’tbelieveit!
Whyhadnooneevertoldmeaboutthis?
Itturnsoutthatmostpeopledidn’tknoworwerejustfindingoutthemselves.ButthankstoGoogle,Isoonrealizedthatthiswasnofluke.Manyothersweresayingthesamethingand Drs.MikeandMaryDanEades hadwrittenaboutthisintheirbestsellingbook, ProteinPower. IalsofoundoutthatsomedoctorsatDukeUniversityhaddoneasmallclinicalstudyconfirmingthatcuttingcarbscanrelievesymptoms.
Whiletherevelationwasagreatrewardinandofitself,forthefirsttimeinmylifeIcouldcontrolmysymptoms,Iwasfarfromsatisfied.Ireallywantedtoknowwhy.Ifremovingmostcarbsstopsheartburn,didthatmeanthatcarbscausedheartburn?
Idecidedtogettothebottomofthingsandstarteddoingresearchonhoweachtypeoffood(fats,proteinsandcarbohydrates)isdigested.Ireadaboutandthoughtaboutthedigestiveprocess–chewing,salivaryamylaseforstarch,stomachacidandpepsinforproteinbreakdown,lipaseforfats,etc.And,asIstartedreadingaboutdigestioninthesmallintestine,alightbulbwentoffinvolvinggutbacteria.
Asamicrobiologist,Ihadgrownandstudiedawidevarietyofbacteriaforyearsingraduateschool.Ialsoworkedwithintestinalbacteriaduringapostdoc.atTufts.Whilemyfocuswasgenetics,weconstantlyneededtogrowenoughbacteriatoworkwith.And,Irecalledtwoimportanttraitsofintestinalbacteria:
1.Theygetthebulkoftheirenergyfromcarbohydrates
2.Mostofthemproducelotsofgas
Dependingonthestrain,bacteriaproducecopiousamountsofhydrogenandcarbondioxidegas.Also,intestinalArchaea,whichlooklikebacteriaunderthemicroscope,butareactuallyaseparatebranchoflife,produceathirdintestinalgas,methane.Carbohydratesarethebestfuelsourceforgasformation.AccordingtoSuarezandLevitt,[1]30gofcarbohydratethatescapesabsorptioninadaycouldproducemorethantenlitersofhydrogengasinsmallintestine.Imaginehowmuchpressurethisamountofgascancreate.Intestinalbacteriaproducesomuchgasthattherehavebeenwelldocumentedcasesofexplosionsduringintestinalsurgery.[2],[3] Thisgavemeanidea:
“WhatifsomeofthecarbsIhadbeeneatingwerenotbeingefficientlydigestedandabsorbedintomybloodsteam,andinsteadtheywerepersistinginmysmallintestine?
Wouldn’ttherebeachancethatmyacidrefluxwastheresultofintestinalgaspressurefromabloomofgas-producingbacteriafedbycarbohydrates?
I.e.mentos inacokebottle”
Couldtheanswerbethatsimple?
Ineededtolearnmoreandfindoutifthisideawasfullofholes.And,Isetouttodestroymyowntheory:
)
Whatwecanagreeon
ThefirstthingIdidwaslearnallIcouldaboutwhatotherscientiststhought.Onethingeveryoneseemedtoagreeonwasthatacidrefluxoccursbecausethegroupofmusclesatthetopofthestomachareunabletokeepthestomach’scontentsfromenteringtheesophagus.Thisgroupofmusclesiscalledtheloweresophagealsphincter(LES).Thestomach’scontentsincludehydrochloricacid,bileanddigestiveenzymes.Butwhydoesacidrefluxoccur?
Accordingtothe NIH:
“GERDresultswhentheloweresophagealsphincterorLESbecomesweakorrelaxeswhenitshouldnot,causingstomachcontentstoriseupintotheesophagus.”
LESrelaxationeventsarecalledtransientloweresophagealsphincterrelaxations(TLESRs).TheLESappearstoundergotheserelaxationevents,evenwhenwearenotswallowing.BothLESpressureandTLESRscanbemeasuredbyatechniquecalledmanometry,whereapressure-sensitivetubeispasseddowntheesophagusthroughtheLES.Thistechniquehasbeenusedformanystudies[4],[5],[6] andclearlyshowthat GERDpatientsexhibit:
∙Moreepisodesofreflux
∙LessLESpressure
∙MorefrequentepisodesofTLESRs
∙MoreextensiverefluxduringTLESRs,particularlyaftermeals
∙Morepressureinthestomach(intragastricpressure)andmorebelching
Iwonderedifsomeoftheseideasmightdisprovemytheoryorweretheysomehowconsistentwithmyownobservations.Ithoughtabouteachobservationtoseeiftherewassomecommonthread.ThoughincreasedpressureinthestomachhadbeenwelldocumentedinGERDpatients,[7] noonehadagoodexplanationaboutwherethepressurewascomingfrom.But,mytheoryclearlyexplainedapotentialsource:
copiousamountsofgasandpressurefrombacterialfermentationinourintestines.
GotGas?
AsforlessLESpressure,youmightbeabletoimagineintragrastricpressure“forcing”theLEStoopenasapossiblemechanismofacidreflux.Clearlyifthisweretooccur,theLESpressuremeasurementwouldbereducedbytheintragastricgaspressure.InotherwordsreducedLESpressureinGERDpatientscanbeexplainedbymytheory.
ThesameanalogycanbeappliedtoexplainTLERsaswellasincreasedrefluxduringTLESRs.ThegaspressureforcingtheLEStoopenwouldbemeasuredasreducedLESpressureorrelaxationeventsbymanometryandbeexpectedtoincreasetheamountofrefluxateineachevent.ThiswouldbeparticularlytrueaftermealsifmalabsorbedcarbohydratesineachmealweredrivingthebacterialgrowthandgasproductionasIsuspected.Thus,mytheoryalsoexplainstheincreaseinTLERsinGERDpatients,particularlyaftermeals.
Whileonthesubjectofgaspressure,thereisonemoreimportantpredictionmytheorymakes.Ifyouweretostoptheprocessofrefluxandbelchingwithoutresolvingbacterialovergrowth,youmightexpectabuildupingaspressureinthestomachandsmallintestine.Onewaytolookatthisquestionistostudypeoplewhohavehadfundoplicationsurgery,wheretheLESissurgicallytightened,thuspreventingrefluxandbelching.ReportsonGERDpatientswhohaveundergonethisprocedureshowthattheysufferfromnewsymptomsincludingexcessivegas,flatulenceandbloating.[8],[9] TheprocedureisaimedatpreventingrefluxbytighteningtheLESmusclessurgically,butthesideeffectsareindicativeoftrappedstomachandintestinalgasaswouldbeexpectedwithuncontrolledmalabsorption,andexcessivebacterialfermentation.
Gotbacteria?
Essentially,Iwasproposingthatexcessdietarycarbscouldpromoteakindofgutdysbiosis(unbalancedgutmicrobiotawithtoomanygasproducingstrains),possiblysmallintestinalbacterialovergrowth(SIBO).Accordingtothisidea,acidrefluxoccursduetomicrobe-inducedgaspressure.AsIcontinuedmyresearch,Iwonderedwhattheworldmightlooklikeifmytheorywascorrect.ThefirstthingIfocusedonwasbacterialovergrowthitself.IreasonedthatyoushouldseeareductioninGERDsymptomswheneveryoureducedbacterialgrowthintheintestine.
Onewaytocontrolexcessivebacterialgrowthintheintestineistogoonalowcarbdiet,becausethistypeofdietlimitscarbohydratefuelthatbacterianeedforgrowth.AsImen
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