Underlying Causes of Acid Reflux - Testing and Natural Treatment
The underlying causes of acid reflux are often overlooked for short-term, band-aid solutions. With the prevalence of acid reflux symptoms, GERD and heartburn all increasing and the typically ineffective conventional treatment options often leading to further chronic problems, this is a blog post that I’ve been wanting to create for my clients, and those who visit my blog, for a very long time. But, better late than never, right!?
From the underlying causes of acid reflux to testing and natural treatment approaches, here’s everything we’re going to cover:
> What are acid reflux, GERD and heartburn and how can you tell the difference?
> What is the antireflux barrier
> The importance of stomach acid and why you likely DON’T have too much
> Causes of acid reflux and GERD
> Testing for the functional underlying causes of acid reflux
> What you can do to address acid reflux naturally
> What’s the difference between acid reflux, GERD and heartburn?
What is acid reflux?
There is a muscular band (a sphincter) at the base of the esophagus (the food pipe) where food enters the stomach known as the lower esophageal sphincter (LES). In conjunction with the diaphragm (also a sphincter), the two sphincters work together like a valve, one inside and the other outside, to narrow or widen the esophagus. The role of these two sphincters is to relax during eating to allow food to enter the stomach and contract afterwards to prevent the contents of the stomach – food and acid – from bubbling back up into the esophagus and throat.
When these sphincters fail and stomach acid and food do bubble back up into the esophagus and throat, this is what we call ‘acid reflux’. The symptoms of acid reflux include:
> Heartburn (see below).
> Regurgitation of food with a burning sensation or bitter taste at the back of the throat.
> A general complaint of stomach ailments such as nausea after eating, burping, bloating, and upper abdominal discomfort.
What is GERD?
GastroEsophageal Reflux Disease is a more severe, chronic form of acid reflux. Generally it is accepted that if you suffer from acid reflux more than twice a week you have GERD, but often it happens more frequently than that. The symptoms of GERD are the same as acid reflux but in addition you may have a cough, laryngitis, chest pains, asthma or poor sleep. NERD is non-erosive reflux disease. The symptoms can be the same but there is no erosion to the esophagus, and therefore no structural damage.
What is Heartburn?
Heartburn is a symptom of Acid Reflux and GERD. It doesn’t really affect the heart but because the pain from the refluxing acid burns up the esophagus and into the throat, the burning sensation is felt in the chest near the region of the heart. In fact it is often confused with angina or chest pain.
What is the antireflux barrier?
The lower esophageal sphincter (LES), the diaphragm, the phrenoesophageal ligament (a ligament that attaches the esophagus to the diaphragm) and the gastroesophageal junction (GEJ) are the main components of the antireflux barrier. The GEJ is like a flap-valve that works with the LES to stop reflux. Incompetence of the antireflux barrier has been considered the main underlying cause of acid reflux. In the following section I’ll explain further but for now let me say that the LES requires sufficient quantities and acidity of stomach acid to remain closed, and that too little stomach acid can potentially cause acid reflux and GERD, NOT too much stomach acid. It doesn’t matter if you have too much acid, if your LES is working correctly, it’s unlikely that you will experience acid reflux.
The importance of stomach acid
Stomach acid plays an important role in digestion and our immune system. Not only does it break down food particles, but it can also kill unwanted pathogens and prevent them from entering other systems of the body. Food that has been chewed and swallowed is further broken down by stomach acid, in the ‘churning and burning’ stage of digestion.
It’s so critical that we don’t need to control it consciously. Starting to eat, even just thinking about it, stimulates secretions of stomach acid when digestion is working well. There are different phases at which the stomach acid is released but generally, by the time that first bit of breakfast hits the stomach, your gastric juices are well and truly flowing!
The gastric juice that we often call ‘stomach acid’ is very acidic and made up of a number of components throughout the upper GI tract, including:
> Hydrochloric acid (HCL) - secreted by the parietal cells in the stomach.
> Amylase - from saliva which breaks down carbohydrates before they hit the stomach.
> Pepsin - digestive enzymes produced in the stomach that break down proteins. Pepsin is activated in low pH (acidic environment).
> Gastric lipase - produced in the stomach, helps break down fats.
> Intrinsic factor - helps your body absorb vitamin B12.
Hydrochloric acid (HCL) makes up the majority of stomach acid and so it’s worth understanding a little bit more about it and the important role it plays in proper digestion and in the development of acid reflux. > HCL has a pH range of 0.5 to 3.0. The pH scale ranges from very acidic (0) up to very alkaline (14). As a comparison, battery acid and stomach acid have a similar pH of around 1-2. Water’s pH is 7, baking soda is 8-9 and ammonia 11-12.
> HCL also stimulates the closure of the LES (lower esophageal sphincter) which is critical to preventing acid reflux and GERD from occurring - more on this below.
> HCL activates the release of the enzyme, pepsin. When pepsin is released into the stomach it goes to work on proteins, breaking them down into their smaller forms of amino acids and peptides. These processes aid the digestion of now-broken-down protein molecules throughout the rest of the GI tract.
> HCL triggers the release of lingual lipase (in the mouth) as well as gastric lipase (in the stomach), an enzyme that helps break down fats into smaller molecules called glycerol and fatty acids.
> HCL also has the ability to convert minerals into absorbable nutrients for the body’s use. Low HCL secretion decreases the bioavailability of nutritionally important minerals, such as iron, zinc, and calcium. By that I mean the body can’t absorb and use these minerals, and they are excreted with other wastes.
What are the causes of acid reflux and GERD?
We are going to go into a fair amount of detail here so I’m going to give you the short answer, with a diagram, and then all the additional info below. In most instances, acid reflux is caused by:
An impaired antireflux barrier - so that stomach acid can reach the esophagus; and
Increased intra-abdominal pressure - to force the stomach acid upward toward the esophagus
Without both of these, stomach acid will be contained in the stomach and symptoms of acid reflux will not be a problem. So the next question is: what causes an impaired antireflux barrier and increased abdominal pressure? The short answer, that is responsible for acid reflux in the vast majority of my clients, is: low stomach acid. And here’s why...
How low stomach acid causes acid reflux
Low stomach acid can cause acid reflux and GERD via two main mechanisms. The first is to do with the LES component of the antireflux barrier and the second is its impact on intra-abdominal pressure:
> Low stomach acid and the antireflux barrier - High stomach acidity (low, or more acidic pH) creates pressure on the LES which closes to prevent acid entering the esophagus and causing symptoms. The LES acts like a muscle and without sufficient stomach acidity keeping it toned, may become weak and less effective over time.
> Low stomach acid and intra-abdominal pressure - This can happen in a number of different ways but essentially relates to increased gas production from the fermentation or putrefaction of food particles. Low stomach acid can create an environment that allows bacteria to overgrow in the GI tract. If this occurs, certain carbohydrates are likely to be fermented by the bacteria (this is their fuel source) which causes excess hydrogen gas (particularly in the upper part of the small intestine), leading to increased pressure in the stomach. The other mechanism relates to the putrefaction of undigested proteins, often after eating meat. Because stomach acid is essential to the breakdown of these proteins, when stomach acid is low, these proteins begin to rot and produce excess gas in the stomach, leading to increased intra-abdominal pressure.
Other contributing causes of acid reflux
While we are focussing on low-stomach acid as the most common cause of acid reflux and GERD, it’s worth touching on some of the other causes of an impaired antireflux barrier and increase intra-abdominal pressure. For anyone with low-stomach acid, these other causes may kick-start the process or make symptoms more frequent:
Other causes of impaired antireflux barrier
> Medications: some prescription medications can have heartburn as a side effect because of their impact on the function of the LES.
> Scleroderma (systemic sclerosis): a rare autoimmune condition where the body attacks the connective tissue and creates a thickening and hardening of the skin/tissue. If present in the esophagus, the LES’s function can become impaired.
> Pregnancy: hormones that relax the muscles during pregnancy can also relax the LES.
Other causes of intra-abdominal pressure
> Obesity. While obesity can’t cause acid reflux or heartburn directly, it is certainly a risk factor. It is thought that pressure from adipose tissue around the abdomen pushes the esophagus into the chest cavity forming a hiatal hernia (see below). Obesity is also thought to cause the LES to relax.
> Laying flat and bending over. Again, not a direct cause but if you do have acid reflux then laying down may exacerbate the problem as your stomach and head are now at the same level, and the contents can flow back the way they came. Bending over can have a similar effect.
> Hiatal hernia - With a hiatal hernia (also known as a hiatus hernia), part of the stomach pushes into the chest cavity. It enters via an opening where the esophagus passes on its way to the stomach, preventing the LES from closing. It is usually caused by a weakness of the diaphragm muscle, but not everyone who has a hiatal hernia develops acid reflux or GERD.
> Pregnancy - In later stages of pregnancy the growing fetus can put pressure on the mother’s abdomen and diaphragm, forcing stomach contents back up toward the esophagus.
Causes of Low Stomach Acid
If acid reflux and GERD are most commonly caused by low stomach acid, the next question to answer is: what causes low stomach acid? Here are the main culprits:
> H.pylori - If Helicobacter pylori bacteria manages to colonise in the stomach, it produces ammonia as a by-product. Ammonia is an alkali that neutralises stomach acid. In addition, H.pylori can inhibit acid production directly as well. Given that up to 50% of the population is thought to have H.pylori, it’s no wonder we have an ever-growing number of acid-reflux sufferers.
> Age - As we age our gastric acid secretions become less. This is why GERD is a condition often associated with older populations.
> Stress - Chronic stress, including extended strenuous exercise, psychological stress or other prolonged attacks on the immune system from physical, mental-emotional or infections sources can all impact the production of stomach acid.
> Vitamin or mineral deficiencies - zinc and vitamin B6 are considered essential for the production of Hydrochloric acid (HCl) and deficiencies in either may lead to low stomach acid.
> Proton pump inhibitors and antacids - These medications are specifically designed to reduce the volume and acidity of stomach acid. As we now know, this might not be such a great idea when it comes to reducing acid reflux symptoms long-term.
> GI surgery - Surgical procedures, such as gastric bypass surgery, can reduce the amount of stomach acid produced.
Testing for the functional underlying causes of acid reflux
Effective natural treatment of acid reflux and GERD requires identifying exactly what is going on in the body and to pinpoint the underlying root cause(s). To do this from a Functional Health perspective, we want to look at three main things:
Levels of stomach acid
While it would be nice to get a baseline on stomach acid, there is no easy way to do this outside of the medical setting. Invasive tests can measure the pH level and amount of acid in the stomach and the Heidelberg Stomach Acid Test can report pH using a swallowed radio-transmitter capsule. As such, I find looking at outcome measures on comprehensive stool testing to be the most efficient method. Most functional stool testing provide information about ‘products of protein breakdown’ and fat malabsorption markers (like ‘steatocrit’ and ‘total fecal fat’) as an effective means of identifying potentially low stomach acid levels - both in acidity and amount. Because stomach acid is critical for breaking down proteins and fat, these will not be well-digested and absorbed by those with insufficient acidity or amount of stomach acid, and will be evident in the stool.
H.pylori and other GI pathogens
Testing for Helicobacter pylori (H.pylori) and other GI pathogens is what I focus on when identifying the underlying root causes of acid reflux. Because even if you do identify low levels of stomach acid, the real question is ‘why?’. This is where bacterial infections (not only from H.pylori) and overgrowths, the most common causes of low stomach acid and reflux symptoms I see in practice, come into play.
I like to include a H.pylori marker on all DNA (PCR) stool testing I order as this is one of the most effective methods for detection at the moment. We also get comprehensive information about other GI infections from this style of testing that may be contributing to symptoms. Other options that can be done as standalone testing for H.pylori include urea breath testing or antigen testing, both commonly available as a single test from your doctor.
I’ve written an entire blog post on testing for root causes of IBS HERE, including stool testing, so if you’d like more information then make sure you check it out. I’m also in the middle of writing a blog post on H.pylori so will include a link to that here when it’s finished.
Small Intestinal Bacterial Overgrowth (SIBO)
Given that hydrogen gas, caused by bacterial overgrowth, is a common cause of increased intra-abdominal pressure (IAP), getting tested for SIBO is worthwhile for anyone suffering from symptoms of acid reflux. I have written an entire blog about SIBO testing HERE and the current gold-standard which is the 3-hour lactulose breath test for both hydrogen and methane gasses.
Another note about SIBO is that H.pylori is commonly associated with elevated methane gas levels from baseline on SIBO breath testing, so I also use this as a clue for identifying H.pylori infections.
Approach to acid reflux natural treatment
The process for treating acid reflux naturally needs to be holistic and focus on the underlying root cause. For the vast majority of my IBS clients, the root cause is low stomach acid. So, here’s an overview of my typical four-step approach:
1. Address causes of low stomach acid
The most common causes that I see, and have mentioned above, are H.pylori and other GI infections. H.pylori is thought to infect around one-third of the population in developed countries. With many of those infected considered to be ‘asymptomatic’, some researchers believe it to be a normal part of the digestive flora. However, in my experience working with symptomatic clients with H.pylori, removing the infection has a positive effect on acid reflux symptoms.
There are multiple treatment options available for H.pylori, from antibiotics to natural antimicrobials such as mastic gum and allicin, and even Matula Tea. I will write a detailed blog post on my approach at a later date, but I recommend working with your practitioner to address H.pylori if you are symptomatic and have this bacteria in your GI tract. It can be hard to remove, especially when the infection has migrated into the liver and/or gallbladder.
2. Remove sources of intra-abdominal pressure
Beyond H.pylori, other gut infections and overgrowths can also contribute to acid reflux symptoms, primarily through an increase in intra-abdominal pressure. This is particularly true of small intestinal bacterial overgrowth (SIBO). This is because the main consequence of SIBO is an increase in hydrogen or methane gasses in the small intestine. I’ve written a whole blog series on SIBO that starts HERE if you’d like to learn more about this condition as well as testing and natural treatment options.
It’s also worth noting some other key points about SIBO here. Firstly, hydrogen is a preferred energy source for H.pylori so, along with other hydrogen-producing gut infections, SIBO can help feed this common cause of low stomach acid. The other thing is that H.pylori is associated with greater methane production so can be confused for a positive methane SIBO result on a lactulose breath test, all while adding to increased intra-abdominal pressure.
An associated step in the process that will help fight both SIBO and acid reflux symptoms is to reduce fermentable carbohydrates in the diet. When carbohydrates ferment (with the help of bacteria) they produce a lot of gas, which can contribute to increased IAP. As such, reducing the amount of fermentable carbohydrates may reduce symptoms in the short-term. The paleo, Low-FODMAP (for very short periods of time only) and SCD diets are a good place to look for ideas on reducing carbohydrate intake. I say, ‘short-term’, because carbohydrates from sources such as fruits, vegetables and pseudo-grains are essential to feeding a healthy and diverse microbiome, so are not something you want to eliminate long-term.
If SIBO and fermentable carbohydrates don’t give you a problem, you may find that simply eating easily digested foods reduces the burden on your stomach acid reserves. This includes more cooked, rather than raw vegetables and avoiding large amounts of animal proteins in one meal. Heavy protein meals including animal meat, can often be a struggle for those with low stomach acid to digest and so substituting these for more easily digestible foods might provide short-term relief. Options are protein powders, gelatin and collagen products. For those who tolerate soy, you can also use fermented soy foods such as tempeh and miso for proteins. Products I like to use with my clients include:
> Pea Protein: Australian Supplier, Amazon
> Bone broth protein: iHerb Australia, Amazon
> Collagen powder: iHerb Australia, Amazon.
Again, this is a short-term solution but may help improve symptoms while we’re identifying and healing the underlying imbalance.
Other dietary considerations are acid vs. alkaline foods as often clients will struggle with highly acidic food sources, and the basics of reducing alcohol, sugar, processed foods, caffeine and chocolate, and sometimes citrus and spicy foods can be helpful. Experiment with these as everyone is different.
3. Support stomach acid and digestive secretions
HCL Supplementation Because acid reflux is commonly the result of low stomach acid, supplementing with HCL can be supportive in reducing these symptoms in most clients.
Thorne Research, HCL is a good quality HCL supplement I like to use with my clients (iHerb Australia, Amazon). They generally take 1 capsule with main meals. Other options that combine HCL with additional digestive supports like pepsin, pancreatin and ox bile for clients who struggle with protein and fat digestion is Thorne Bio-Gest (iHerb Australia, Amazon). This is recommended at 1 capsule at main meals for up to 4 weeks. If you use this product, it is recommended you take a break every 4 weeks.
It’s important to note that medical best practice outlines that HCL should not be taken by anyone who is also using any kind of anti-inflammatory medication such as aspirin, ibuprofen, corticosteroids, indocin, or other NSAIDS. These medications can damage the gut lining and be further aggravated by HCL supplementation, potentially increasing the risk of gastric bleeding or ulcers. This is something you should discuss with your doctor if you'd like more information.
HCL supplementation may also not be advisable in those who test positive for H.pylori. While some practitioners don’t consider the two to be incompatible, I prefer a more conservative approach. That is, I don’t have my clients take HCL until H.pylori is cleared. H.pylori likes a more alkaline environment in the stomach to live, however uses acid to proliferate and grow. This means he will move in, make your stomach less acidic, then use the acid supplementation you take to increase numbers. And so the cycle continues.
Digestive bitters An alternative approach to stimulating stomach acid production is through the use of bitter herbs, also known as ‘digestive bitters’. Such herbs have been used to stimulate and improve digestion in many traditional cultures for thousands of years. In more modern history, they have been the domain of ‘alternative health’ practitioners but recent studies have confirmed the ability of digestive bitters to increase digestive juices such as HCL, pepsin, bile and pancreatic enzymes. This is because the body has evolved to use bitter taste as a warning signal against the ingestion of potentially toxic substances, which require more stomach acid to kill.
4. Restore beneficial bacteria and a healthy mucosal lining in the gut.
When we’re gut healing from specific symptoms such as GERD and acid reflux it’s important to take a more comprehensive approach so that you reduce the risk of relapse, reinfection or other issues with your gut. To complete the process you need to work on the microbiome and keeping it in healthy balance to avoid infections like H.pylori in the future.
To help restore the gut microbiome, I like to focus on food diversity, food-based probiotics from fermented foods and targeted probiotic supplementation. While many practitioner-recommended probiotics will likely assist in supporting the gut microbiome, a specific strain of Lactobacillus has been shown to simultaneously improve acid reflux symptoms. The strain known as Lactobacillus reuteri DSM 17938 and available as BioGaia ProTectis (iHerb Australia, Amazon) was found in a recent study of infants with gastroesophageal reflux to reduce regurgitation episodes, amongst other GI benefits. This is partly related to it’s ability to reduce intra-abdominal pressure through ‘reduced gastric distension and accelerate gastric emptying’. It’s branded as a children’s product but can be used in adults at a daily dose of 10 drops before bedtime, something my clients have had good success with.
Fermented foods, especially dairy-based ferments such as kefir (if you can’t tolerate dairy you can use water kefir as an alternative) are supportive of gut lining repair. Other options include fermented vegetables such as sauerkraut and fermented nuts such as ‘cashew cheese’. Kombucha is a common ferment, however will not work well for anyone with SIBO.
Bone broth is also effective in restoring a healthy mucosal lining in the stomach, with many of my clients reporting positive outcomes from regular, daily use. Whether it is in home-made soup form or as a powdered supplement, bone broth is a helpful addition to any gut-healing protocol.
Other short-term supports to reduce GERD and acid reflux symptoms
Getting to the root cause of GERD and acid reflux symptoms though testing and natural treatment can take time. This is why I like to support my clients with a few short-term symptom reducing suggestions while we work through the process. I’ve left this until the end as I don’t want to distract from the real goal for those suffering from GERD and acid reflux; finding and healing the root cause.
Here are some options you might like to consider that have worked for my clients:
> DGL (deglycerized licorice): It is used to increase mucus production and protect the stomach and oesophagus from acid.
> Aloe Vera Juice: Decolorized and purified aloe vera juice is a common option used to reduce acid reflux symptoms. Start with a small amount, like ¼ cup and build slowly as tolerated. Aloe vera dosage will vary depending on product and whether the laxative properties have been removed (decolorization).
> Slippery Elm: Can be taken orally to coat and soothe inflamed tissues in the gastrointestinal tract. It can also help stimulate more mucus production in the intestines.
> Marshmallow root: Can help soothe irritation and inflammation in the digestive tract.
> GI Encap: this is a specific formulation of all of the above ingredients by Thorne Research (iHerb Australia, Amazon) that I use with my clients. Take 1-2 capsules with meals to support the stomach and oesophagus when you have GERD and acid reflux symptoms.
If you’ve made it this far, I hope you’ve learnt a lot about the actual underlying causes of acid reflux and GERD. If you have been struggling with GERD or acid reflux symptoms and you would like to get tested and have a personalised healing protocol developed specifically for you, please get in touch. I’d love to work with you.
Healing the gut and our digestive function is a journey. If you are ready to begin yours, please head to the ‘Work With Us’ page to learn more about how I work online with clients in many countries to test for and treat the root causes of GERD and acid reflux symptoms we’ve discussed above.
Note: Affiliate links for iHerb and Amazon have been included in this blog post. These do not adversely affect the price you pay.