Gastro-esophageal Reflux Disease (GERD)

GERD Symptoms, Causes & Treatment

Indigestion and reflux is caused by impaired digestion. It is a common problem and is frequently associated with gastro-esophageal reflux disease (GERD) and more commonly known as heartburn.

Gastro-esophageal reflux disease is a disorder resulting from repeated reflux of acid and gastric contents into the esophagus, mainly caused by lower esophageal sphincter (LOS) not functioning correctly. It is very common, occurring in 10-20% of people in Western nations. When the pH in the gut doesn’t get acidic enough, to less than 3, the LOS doesn’t close properly causing reflux.

Reflux esophagitis is a complication of GERD, resulting from inflammation and damage to the esophageal mucosa.

Barrett’s esophagitis is a complication of GERD and is characterised by mucosal cell changes in the lower esophagus. It is a precursor to cancer of the esophagus.

Causes & Risk Factors of GERD

• Lower esophageal sphincter (LOS) impaired function
• Poor esophageal acid clearance due to lowered peristaltic action
• Delayed gastric emptying e.g. peptic stricture, peristaltic dysfunction, low fibre and high meat diet
• Increased gastric pressure: over-eating, pregnancy, obesity, tight clothing
• Excessive or low gastric acid production:
• Most research suggests that GERD sufferers produce more than or normal amounts of gastric acid, clinically this is often not the case though
• Low gastric acid production is often seen in the elderly or in people on proton-pump inhibitors. Low gastric acid leads to poor digestion of food, encourages bacterial growth and may cause relaxation of the LOS.
• Food allergy and sensitivity
• In infants and toddlers, GERD is frequently linked to a dairy allergy
• There is an increased risk of GERD in people with coeliac disease. Chronic GERD sufferers should be screened for Celiac Disease. Symptoms can improve rapidly with a gluten-free diet
• Poor dietary habits
• Sugar and refined carbohydrates: causes rapid secretion of gastric acid which has no proteins or fats to buffer
• Overeating: amount of food exceeds digestive acid/enzymes leads to undigested food passing into small intestine
• Foods that increase acid secretion: alcohol, coffee, red meat
• Foods that can reduce LOS pressure and impair LOS competence: alcohol, coffee, chocolate, fatty meals, peppermint
• Foods that slow gastric emptying: alcohol, fatty foods
• Foods that impair esophageal motility: alcohol
• Foods that irritate esophageal mucosa: spices, salt, coffee, alcohol, acidic foods (tomatoes, citrus, soft drinks), excessively hot/cold foods
• Large meals, improper chewing and eating meals too quickly
• Drinking water with meals
• Gut dysbiosis (e.g. H.pylori infection): causes production of endotoxins, increasing acidity in small intestine and decreasing acidity in stomach
• Overweight and obesity
• Pregnancy: relaxation of LOS due to effect of progesterone and relaxin
• Certain medications: some antibiotics, NSAIDs, iron supplements, beta-agonists, anti-cholinergics, calcium channel blockers, progesterone
• Smoking: delays gastric emptying and causes relaxation of the LOS
• Hiatus hernia: relatively common in patients with GERD
• Stress: due to its effect on digestive function

Symptoms of GERD

• Substernal or epigastric pain, burning, discomfort – may radiate to sides of chest, neck, jaw
• Pain worse for bending over, lying flat, lifting, exertion, after meals, hunger (food can temporarily relieve then symptoms come on ½ hour after eating); better for upright posture, antacids
• Regurgitation
• Sour taste in throat
• Nausea
• Pain on swallowing
• Persistent cough / hoarseness

Differential diagnosis

• Peptic ulcer or gastritis
• Angina or myocardial infarction
• Acute pancreatitis
• Kidney disease
• Respiratory disease
• ENT disease
• Esophageal carcinoma
• IBD
• Hepatitis

TREATMENT STRATEGY FOR GERD

• Relieve symptoms
• Address intestinal dysbiosis / SIBO if present
• Ensure gallbladder is functioning correctly
• Identify / eliminate exacerbating factors (e.g. irritating foods, food allergens, overeating, stress, intestinal dysbiosis, celiac disease, etc)
• Assess and balance gastric acidity
• Support digestive function and speed gastric emptying
• Decrease intra-abdominal pressure
• Improve tone of lower esophageal sphincter
• Decrease esophageal inflammation / oxidative damage / promote healing
• Support nervous system
• Prevent complications (Barrett’s esophagitis, esophageal carcinoma)

Diet plan guidelines for GERD

• Avoid foods that may irritate the esophageal mucosa and impair LOS:
• Acidic (tomatoes, citrus, soft drinks), spicy foods, fatty and fried foods, sugar and sweetened foods, alcohol, very hot or cold foods can irritate mucosa
• Chocolate, coffee, alcohol, nicotine, peppermint can impair LOS
• Chewing gum: increases stomach acidity
• Identify and eliminate food allergens and sensitivities
• Gluten is commonly implicated and all sufferers of GERD should be screened for coeliac disease
• Infants and toddlers can benefit from a dairy-free diet. If they are breast-fed, the mother should go onto a dairy-free diet. If they are formula-fed, the mother should be encouraged to re-lactate or substitute formula with a whey-based formula
• Facilitate proper digestion of food:
• Avoid excessive animal proteins and fats: requires increased stomach acid and delays gastric emptying
• Increase fibre: speeds gastric emptying
• Increase bitter foods e.g. rocket, radicchio, bitter greens
• Eat slowly, chew food properly, eat in a calm, relaxed manner
• Avoid drinking water with meals as it dilutes gastric acid
• Decrease intra-abdominal pressure:
• Eat smaller, more frequent meals
• Ensure correct posture while eating
• Eat at least 3 hours before bed
• Avoid bending over or lying down immediately after meals
• Prop up head of bed
• Weight loss diet if indicated
• Soothe and repair esophageal mucosa
• Include soothing foods such as porridge and yoghurt
• Include antioxidant foods such as brightly coloured fruits and vegetable, legumes, green tea.
• Carob powder: studies have shown carob powder added to formula to be effective in decreasing severity and frequency of vomiting in infants with GERD
• Include probiotic foods to balance gut flora: natural yoghurt, kefir, sauerkraut, etc.
• Honey is traditionally used as a demulcent in reflux – may be taken after meals or before bed as a preventative.

Supplements that support GERD

• Betaine hydrochloride supplement with meals: if low stomach acid is a factor
• Slippery elm : Helps soothe esophageal mucosa
• Glutamine: to repair esophageal mucosa
• Vitamin C and bioflavonoids: to strengthen connective tissue
• Broad-spectrum probiotics: to balance gut flora
• Lactobacillus reuteri MM53 has been shown to accelerate gastric emptying
• Zinc: to facilitate mucosa repair and support gastric acid production in hypochlorydia

Herbal medicine treatment for GERD

**best to use low-alcohol or glycetract forms, tablets or powders as alcohol may be a trigger for GERD

• Demulcents: licorice, marshmallow, slippery elm: most effective when given in powdered form mixed into a little water or apple juice to form a slurry or gruel. Demulcents can be used ‘on demand’ or taken after meals or before bed for a preventative effect.
• Mucosal repair: calendula, aloe, marshmallow, licorice, aloe
• Antacids: meadowsweet, alfalfa
• Anti-inflammatory: meadowsweet, turmeric, licorice, chamomile
• Bitters and digestive stimulants: gentian, ginger. Help to stimulate digestion, speed gastric emptying and exhibit mucosal protective activity. However, caution should be used as bitters may increase gastric acid and worsen symptoms of GERD
• Tone /repair lower esophageal sphincter: geranium, yarrow, calendula, bilberry, gotu kola, witchhazel, agrimony (caution with long-term use of high-tannin herbs)
• Nervines: chamomile, lemon balm, passionflower
• Cholagogues: dandelion, St Mary’s thistle, celandine

Lifestyle / Physical measures to support GERD

• Decrease excess weight
• Quit smoking
• Relaxation and stress management
• Avoid restrictive clothing, lying down, bending over, lifting, exercise after meals
• Raise head of bed 10-12cm with blocks or pillows under mattress
• Sleep on left side: reduces LOS relaxation and reflux episodes

FUNCTIONAL MEDICINE TREATMENT OF GERD

The above nutritional and herbal considerations may assist in the relief of GERD and heartburn symptoms. 

The underlying cause needs to be identified and addressed to have long lasting effects and enable the patient to be symptom free, without requiring ongoing supplementation to relieve symptoms. 

Investigations into digestive function, advanced stool testing, SIBO, intestinal permeability, gall bladder function, food intolerances and methylation are often indicated.

At our Perth clinic of Advanced Functional Medicine we have experience with GERD and other digestive disorders. 

If you or a family member are require assistance with GERD / chronic indigestion or other digestive disorder we would love to hear from you.  How did you resolve your symptoms?  What are the main triggers for you?  Please write a comment below.

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