By a specialist in ear, nose and throat diseases. Jeanne A. Rungby, info@rungbyclinic.com
What is reflux:
Reflux, also called gastroesophageal reflux disease (GERD) is a condition that both general practitioners and ear doctors see quite frequently in daily practice. You don't see many people with reflux in the hospital wards, and then the patient is usually admitted for other reasons.
Reflux is caused by the backflow of stomach acid into the esophagus, throat, pharynx, mouth, sinuses, even the ears and generally the upper respiratory tract, which starts at the nose. Repeated or chronic impact of mucous membranes, which are not designed for it, with stomach acid, which has a low pH (very acidic), creates a wide range of problems in the upper respiratory tract. There is irritation and swelling of the mucous membranes, increased mucus and the natural bacterial flora changes.
The typical symptoms, seen from an ENT perspective, are the following: dry cough especially at night, tendency to runny nose, a feeling of a lump in the throat, fear of cancer, false swallowing, hoarseness, sometimes - but far from the rule - heartburn, acid regurgitation and chest pain. Added to this is burning and stinging in the mouth and tongue, chronic mucus in the nose and sinuses, bad breath, frequent infections in the upper respiratory tract and the middle ear. The dentists will probably add periodontosis.
Reflux can be divided into two categories.
Open reflux , which causes a burning sensation in the throat and chest pain, which can be confused with the symptoms of a blood clot/lack of oxygen in the heart. If the patient drinks a glass of cold water, which flushes the acid away from the esophagus, immediate relief occurs. This can be caused by overeating, obesity and pregnancy.
The silent (hidden) reflux , which is usually caused by a hernia or a weak diaphragm muscle, is more difficult to diagnose, as the patients most often deny (in my personal experience) heartburn and acid reflux. It is slightly more frequent in women than men. It is necessary to carry out a binocular examination of the pharynx, esophagus and stomach, mostly to rule out stomach ulcers and cancer. The ear doctors in Denmark carry out the first part of this work by laryngoscopy with a scope inserted through the nose. Chronic reflux is manifested by a loose, lumpy swelling of the area between the opening of the esophagus and the throat. Sometimes watery swelling of the vocal folds (results in hoarseness) and the mucous membranes above (tendency to runny) is also seen. In cavum oris, coatings are often seen on the tongue and yellowish discoloration of the back chewing teeth.
What were we told?
We were told that reflux is caused by too much stomach acid. And that the treatment was therefore about reducing the amount and pH of stomach acid. That we should therefore start treatment with proptone pump inhibitors, PPIs, which reduce the amount and acidity of stomach acid.
IT IS WRONG THAT REFLUX IS DUE TO TOO MUCH STOMACH ACID.
I wish I had learned this earlier in my career!
Reflux is caused by too little stomach acid.
Now how can it be connected?
When we eat, the production of stomach acid must naturally increase. This lowers the pH in the stomach. This triggers closure of the lower esophageal sphincter, i.e. at the bottom of the esophagus, so that stomach acid does not flow backwards. This sphincter, called the LES, is controlled by the pH of the stomach. If the stomach acid is not sufficiently acidic, the LES will not close properly, as the LES acts as a valve between the stomach and esophagus. This can lead to stomach acid leaking up into the esophagus, causing the aforementioned reflux ailments.
Illustration No. 1 (from Source No. 1)
Why is stomach acid important?
Stomach acid, primarily consisting of hydrochloric acid (HCl), plays a crucial role in the body's digestive and health processes. Here are some of the main functions and reasons why stomach acid is essential:
1. Protein digestion
Activation of Enzymes : The stomach acid activates enzymes such as pepsin, which are necessary for the breakdown of proteins into smaller peptides and amino acids. Without sufficient stomach acid, protein digestion can become inefficient, leading to protein deficiency.
2. Nutrient absorption
Vitamins and Minerals : Stomach acid is needed to release and absorb certain vitamins and minerals, such as vitamin B12, iron, calcium and magnesium. For example, the absorption of B12 requires a sufficient amount of acid to release it from food.
3. Protection against Microbes
Sterilization : Stomach acid acts as a barrier against harmful microorganisms that can enter the digestive system through food and drink. The low pH helps kill bacteria, viruses and parasites, reducing the risk of infection.
4. Digestive signaling
Hormonal Regulation : Stomach acid stimulates the release of hormones such as secretin and cholecystokinin, which are important for the regulation of digestion. These hormones help signal the pancreas to release enzymes and bile necessary for breaking down food.
5. Functionality of the digestive system
Optimal pH : Stomach acid maintains the optimal pH level in the stomach, which is necessary for efficient digestion. Without sufficient acid, imbalances can occur, leading to problems such as bloating, gas and discomfort.
6. Prevention of Diseases
Link to Chronic Conditions : There is evidence that low stomach acid can be linked to a number of chronic diseases, such as autoimmune disorders, allergies and digestive problems. Ensuring adequate stomach acid can therefore play a role in preventing such conditions.
7. Influence on intestinal flora
Healthy Bacterial Balance (the microbiome) : Stomach acid helps maintain a healthy balance of bacteria in the gut by limiting the growth of harmful bacteria and supporting the growth of beneficial bacteria.
Stomach acid is therefore not only important for digestion, but also for protecting the body against infections, ensuring optimal nutrient absorption and regulating the entire digestive system. Without sufficient stomach acid, many health problems can occur, underscoring its importance to overall well-being.
Why is proton pump inhibitor (PPI) treatment a big problem?
Acid Suppression Problems : Acid pump inhibitor drugs are widely overused, often misunderstood, and linked to various chronic health problems due to the misconception that acid reflux is caused by too much stomach acid.
Health Risks : Long-term use of proton pump inhibitors (PPIs) and similar medications can lead to serious side effects, including increased mortality, heart events, kidney and liver disease, infections, and dementia (see sources)
Chronic conditions : Low stomach acid is associated with several chronic conditions, including allergies, asthma and digestive problems. Many patients see improvement when their stomach acid levels normalize.
Causes of Acid Reflux : Acid reflux is often linked to a lack of stomach acid rather than an excess. Contributing factors include aging, diet, autoimmune conditions, and certain medications.
Natural treatment : Strategies for managing acid reflux and low stomach acid include dietary changes, lifestyle adjustments, and restoring stomach acid production without medication.
Medical overview : The medical community has largely overlooked the importance of stomach acid and prioritized drug use over evidence-based treatments.
Changing Perspectives : As awareness of the risks of PPIs grows, there is a movement toward seeking safer, natural alternatives to treat acid reflux and related conditions.
· Proton pump inhibitors are addictive due to the rebound effect. In practice, this means that reflux increases sharply upon cessation, which triggers pain, which is why weaning is difficult and must take place gradually.
When does reflux worsen?
1. Aging
With age, the production of stomach acid often decreases. People over the age of 60 often experience a significant reduction in stomach acid production, which can contribute to acid reflux. This can also make it more difficult for the body to absorb nutrients such as B12 and minerals.
3. Diet and Lifestyle
Certain foods and lifestyle choices can contribute to acid reflux, including:
Sugar and carbohydrates from particularly highly processed foods, wheat bread and pasta should be minimized, as they feed the "wrong" gas-producing bacteria in the gut, which give retrograde pressure on the stomach. Soft drinks and sweets are also a "no go".
Caffeinated drinks : Like coffee and soft drinks can irritate the stomach. However, coffee also has benefits, so the solution is to limit the amount of coffee to the morning and afternoon.
Chocolate : Contains substances that can relax the LES. However, dark chocolate has other positive health effects. The solution is to avoid chocolate in the evening before bed.
Alcohol : Can both irritate the stomach and relax the LES. Alcohol also kills the bifidobacteria in the gut and thereby changes the microbiome.
Large meals : Can create pressure on the stomach and push acid up the esophagus.
4. Physical Pressure
In hiatus hernia, where part of the stomach bulges up through the diaphragm, increased pressure on the LES can promote reflux. This is especially common in the elderly and women who have given birth.
5. Autoimmune Conditions
Certain autoimmune diseases can affect the cells that produce stomach acid, resulting in lower levels of acid and thus increased risk of reflux.
6. Medication
Some preparations can also relax the LES or affect stomach acid production. These include:
Muscle relaxants : Used to treat asthma and other conditions.
Blood pressure medication : As calcium channel blockers.
Benzodiazepines (sleeping pills) : Used for anxiety and sleep problems.
7. Helicobacter Pylori Infection
This bacteria can cause inflammation in the stomach and negatively affect the production of stomach acid. However, there are a number of problems with the treatment of H. pylori, as the treatment (antibiotics) destroys the intestinal microbiome, which then worsens reflux. It takes a year to rebuild the microbiome with the right probiotics. Some believe that H. Pylori comes because they thrive better when the pH is not low enough. So it is debated whether this bacteria should be treated at all.
8. Energy Needs
Production of stomach acid requires energy, and people with mitochondrial dysfunction, often seen in chronic diseases, may have a reduced ability to produce sufficient stomach acid. Mitochondria are the cells' energy generator.
9. Stress
Stress can affect the digestive system and contribute to reduced stomach acid production and worsen the symptoms of reflux.
Summary
Acid reflux is a complex problem that is often caused by a combination of low stomach acid, lifestyle factors, medications and physical conditions. Treatment of reflux often requires a holistic approach that addresses the underlying causes.
How is reflux treated?
1. Dietary changes
Avoid Trigger Foods : Identify and avoid foods that trigger symptoms, such as wheat bread, pasta, sugar, chocolate, caffeine, alcohol and certain types of spicy food.
Small, Frequent Meals : Eat smaller portions more often to reduce pressure on the stomach. However, avoid eating at night and before lying down.
Fiber : Consuming dietary fiber can help improve digestion. Foods such as fruit, vegetables, flax seeds and chia seeds are good sources of fibre.
Keto diet (meat, eggs, green vegetables, low carbohydrate and sugar) has good effect on mitochondrial dysfunction and for improving the microbiome.
2. Lifestyle changes
Weight loss : If you are overweight, losing weight can reduce pressure on your stomach and improve symptoms.
Tilt the bed. Raise the end of the headboard by 12 – 15 cm. It's a simple way to help prevent acid reflux at night.
Illustration no. 2. (from source no. 1.)
Avoid lying down after eating : Wait at least 2-3 hours after eating before lying down. Avoid eating at night.
3. Natural Dietary Supplements
Aloe Vera Juice : Can have a soothing effect on the esophagus and stomach.
· Vitamin A, vitamin D, vitamin C, zinc, turmeric are known to help heal damaged mucous membranes in the digestive system.
Ginger : Can help reduce inflammation and improve digestion. It can be consumed as tea or in cooking.
Apple Cider Vinegar : Some people find relief by consuming a tablespoon mixed with water before meals, but this does not work for everyone.
Bitter foods 5 minutes before a meal will increase acid production (berberisthe, gentian or artemisia in limited quantities)
4. Herbal medicine
Chamomile : Chamomile tea can help soothe the stomach and esophagus.
Licorice extract : May help protect the stomach and reduce inflammation.
Slippery Elm : This herb can create a protective barrier in the stomach and esophagus.
5. Stress management
Relaxation techniques : Techniques such as meditation, yoga, and deep breathing can help reduce stress, which can worsen symptoms.
6. Regular Exercise
Gentle Exercise : Regular, gentle exercise can help with digestion and reduce weight, but avoid vigorous exercise right after meals.
7. Probiotics
Fermented Foods : Consuming foods such as yogurt, kefir and sauerkraut can help maintain a healthy intestinal flora, which is important for digestion and the immune system.
8. Liquid
Adequate Fluid Intake : Drinking enough water can help with digestion, but avoid drinking large amounts during meals as it can dilute stomach acid. In the case of a verified hiatal hernia, the patient may be advised to have a glass of water standing on the bedside table. The patient can benefit from taking a small sip of water during the night to flush the acid away from the pharynx and esophagus.
Sources: Each source below contains evidence for claims made in this post.
1. Reflux:
https://open.substack.com/pub/amidwesterndoctor/p/the-great-acid-reflux-scam?r=1i19zf&utm_medium=ios
2. Microbiome:
3. Probiotics:
4. Keto Diet:
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