This is the second article in a series on heartburn and GERD. If you haven’t read the first one, I’d suggest doing that first.
The idea that heartburn is caused by too much stomach acid is still popular in the media and the public. But as Daniel pointed out in the comments section of the last post, anyone familiar with the scientific literature could tell you that heartburn and GERD are not considered to be diseases of excess stomach acid.
Instead, the prevailing scientific theory is that GERD is caused by a dysfunction of the muscular valve (sphincter) that separates the lower end of the esophagus and the stomach. This is known as the lower esophageal valve, or LES.
The LES normally opens wide to permit swallowed food and liquids to pass easily into the stomach. Except for belching, this is the only time the LES should open.
If the LES is working properly, it doesn’t matter how much acid we have in our stomachs. It’s not going to make it back up into the esophagus. But if the LES is malfunctioning, as it is in GERD, acid from the stomach gets back into the esophagus and damages its delicate lining.
Here’s the key point. It doesn’t matter how much acid there is in the stomach. Even a small amount can cause serious damage. Unlike the stomach, the lining of the esophagus has no protection against acid.
We’ve been asking the wrong question
In a recent editorial published in the journal Gastroenterology, the author remarked:
Treating gastroesophageal reflux disease with profound acid inhibition will never be ideal because acid secretion is not the primary underlying defect.
I couldn’t agree more. For decades the medical establishment has been directing its attention at how to reduce stomach acid secretion in people suffering from heartburn and GERD, even though it’s well-known that these conditions are not caused by excess stomach acid.
Instead, the question researchers should have been asking is, “what is causing the LES to malfunction?” Since it is universally agreed upon that this is the underlying mechanism producing the symptoms of GERD, wouldn’t it make sense to focus our efforts here?
That’s exactly what we’re going to do in this article.
GERD is caused by increased intra-abdominal pressure
It is well accepted in the literature that GERD is caused by an increase in intra-abdominal pressure (IAP). Acid reflux occurs when pressure causes gastric distention (stomach bloating) that pushes the stomach contents, including acid, through the LES into the esophagus.
According to current thought, factors contributing to this include overeating, obesity, bending over after eating, lying down after eating, and consuming spicy or fatty foods.
For example, several studies have indicated an association between obesity and GERD, and this recent paper in Gastroenterology concluded that increased intra-abdominal pressure was the causative mechanism.
But while I agree that all of the currently accepted factors play a role, I do not think they are the primary causes of the increased IAP seen in GERD.
The two primary causes of increased intra-abdominal pressure
Instead, I believe the primary causes of IAP (and thus heartburn and GERD) are bacterial overgrowth and maldigestion of carbohydrates – both of which are caused at least in part by low stomach acid.
In a nutshell, the process looks like this:
Let’s look at each step in turn.
Low stomach acid causes bacterial overgrowth
As I will explain in the next article, one of the chief roles of stomach acid is to inhibit bacterial overgrowth. At a pH of 3 or less (the normal pH of the stomach), most bacteria can’t survive for more than 15 minutes. But when stomach acid is insufficient and the pH of the stomach rises above 5, bacteria begin to thrive.
The gastrin knockout mouse, which is incapable of producing stomach acid, suffers from bacterial overgrowth – as well as inflammation, damage and precancerous polyps in its intestines. It is also well documented that acid-suppressing drugs promote bacterial overgrowth. Long-term use of Prilosec, one of the most potent acid suppressing drugs, reduces the secretion of hydrochloric acid (HCL) in the stomach to near zero. In one trial, 30 people with GERD were treated with a high dose of Prilosec (40g/day) for at least 3 months. 11 of the 30 Prilosec-treated people had developed significant bacterial overgrowth, compared with only one of the ten people in the control group.
Low stomach acid causes maldigestion of carbohydrates
Stomach acid (HCL) supports the digestion and absorption of carbohydrates by stimulating the release of pancreatic enzymes into the small intestine. If the pH of the stomach is too high (due to insufficient stomach acid), the pancreatic enzymes will not be secreted and the carbohydrates will not be broken down properly.
Bacterial overgrowth + maldigested carbohydrates = GAS!
Though microbes are able to metabolize proteins and even fats, their preferred energy source is carbohydrate. The fermentation of carbohydrates that haven’t been digested properly produces gas. The resulting gas increases intra-abdominal pressure, which is the driving force behind acid reflux and GERD.
When stomach acid is sufficient and carbohydrates are consumed in moderation, they are properly broken down into glucose and rapidly absorbed in the small intestine before they can be fermented by microbes. However, if stomach acid is insufficient and/or carbohydrates are consumed in excess, some of the carbs will escape absorption and become available for intestinal microbes to ferment.
A nasty vicious cycle: the role of hydrogen gas
Hydrogen (H2) is one of the gases produced by bacterial fermentation of carbohydrates. In fact, there have been explosions during intestinal surgery due to the high amounts of hydrogen gas production in the gut. This is significant because a recent landmark study demonstrated that pathogenic bacteria feed on hydrogen gas.
So, the more undigested carbohydrate you have in your gut, the more hydrogen gas bacteria will produce. The more hydrogen gas is produced, the more bacterial overgrowth will occur. And the more bacteria you have in your gut, the more gas will be produced by fermentation of undigested carbohydrate. This becomes a nasty vicious cycle.
There is significant evidence that the carbohydrates consumed in the “standard American diet” contribute to this phenomenon. Fructose is a particular problem. In one study researchers fed fructose to 15 normal adults. They found that more than half of the 15 adults showed evidence of fructose malabsorption after just 25g of fructose, and greater than two-thirds showed malabsorption after 50g of fructose. To put this in perspective, one 12 oz. can of Coca-Cola contains 30g of fructose.
One of the measures of malabsorption used in the study was a hydrogen breath test. Both the 25g and the 50g doses caused a large increase in H2, especially the 50g dose (a 5-fold increase). Bacterial fermentation of carbohydrate is the only source of hydrogen in the human body. This means that the hydrogen measured in the study indeed came from the undigested fructose in the gut.
Certain type of fiber and starch also promote hydrogen production. Almost all of the fiber and approximately 15-20% of the starch we consume escape absorption. The amount of gas that can be produced by undigested carbohydrates is almost hard to believe. According to Suarez and Levitt, just 30g of carbohydrate (equivalent to 1/2 of a small muffin) that escapes absorption in a day could produce more than 10,000 mL of hydrogen gas. That’s equivalent to ten large one-liter water bottles full of intestinal gas!
Finally, a recent study showed that ingestion of lactose (the carbohydrate found in milk) results in an increased number of transient lower esophageal sphincter relaxations (TSELRs), increased reflux episodes, higher esophageal acid exposures, and more severe GERD symptoms. Another study showed that oral administration of fructo-oligosaccharides (FOS) produces similar findings. Together these studies suggest that colonic fermentation of malabsorbed carbohydrates contributes to the pathogenesis of GERD.
Other supporting evidence
If gas produced by microbial fermentation of carbohydrates causes acid reflux, we might expect that reflux could be treated by either 1) reducing bacterial overgrowth or 2) reducing carbohydrate intake.
In fact, that’s exactly what we see. In a study by Pehl, administration of erythromycin (an antibiotic) significantly decreased esophageal reflux. In another study by Pennathur, erythromycin strengthened the defective lower esophageal sphincter in patients with acid reflux.
To my knowledge there have only been two small trials performed to test the effects of carbohydrate restriction on GERD. Both had positive results. A small case series showed a significant, almost immediate resolution of GERD symptoms in obese individuals initiating a very low-carb diet. A more recent study found that a very low-carb diet decreased distal esophagus acid exposure and improved the symptoms of GERD. Perhaps most importantly, the magnitude of the improvement was similar to what has been reported with treatment with proton-pump inhibitors (acid suppressing drugs).
Many researchers now believe that Irritable Bowel Syndrome (IBS) is caused by bacterial overgrowth in the small intestine (SIBO). A study performed at the GI Motility Center in Los Angeles in 2002 found that 71% of GERD patients tested positive for IBS – double the percentage seen in non-GERD patients being examined.
The high prevalence of IBS in GERD patients combined with the recognition that bacterial overgrowth causes IBS is yet another line of evidence suggesting that bacterial overgrowth is also a causative factor in GERD.
A unified theory
To summarize, GERD is caused by increased pressure in the stomach resulting in a malfunction of the lower esophageal sphincter (LES). The increase in pressure is caused by bacterial overgrowth and malabsorption of carbohydrates, both of which are precipitated by low stomach acid. Reducing bacteria loads and limiting carbohydrate intake have both been shown to greatly improve, and in some cases completely cure, acid reflux and GERD.
In the Part III of the series I discuss the connection between GERD and H. pylori, and further evidence supporting the theory that GERD is caused by bacterial overgrowth. Read on!
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{ 79 comments… read them below or add one }
Great article. I will wait for the followup.
Well Chris, more interesting info. Some of this I was familiar with, but found the studies involving the use of antibiotics to treat the bacteria and resulting GERD symptoms especially strengthening the LES intrigues me.
Since I’m still in the early stages of overcoming this condition, could I possibly benefit from a course of antibiotics? And if so, is there an alterntive to erythromycin? It’s been years since I’ve taken any, but got horrible stomach pain when I did. I think it’s just a basic broad spectrum antibiotic, isn’t it?
Secondly, I sensed that dairy was a problem for me due to the milk protein. In particular, it aggravated my asthma because it does cause production of mucous. However, I have recently discovered raw milk and seem to not experience problems with it; either mucus production or reflux. I’m wondering as in the case of yogurt, if the naturally ocurring friendly bacteria in raw milk pre-digests most of the lactose that feeds the bad bacteria in the gut. In addition, perhaps those friendly bugs help keep some of the bad bugs in check that would produce the gas. Your thoughts?
Hi Kim,
I’m not sure if I mentioned this, but I am planning a follow-up to this series on the connection between asthma and GERD.
To answer your question, one of the reasons raw milk is superior to pasteurized milk is that it has lactase in it. Lactase is the enzyme we need to digest lactose, the sugar in milk. In non-dairy consuming societies, lactase production usually drops about 90% during the first four years of life (after weaning), although the exact drop over time varies widely.
Pasteurization kills lactase. This is why so many people have trouble digesting pasteurized milk. But those same people can often digest raw milk without a problem, because it has lactase in it.
The probiotics in yogurt (as well as kefir, sauerkraut, kombucha, kim chi and other fermented foods) can be helpful in re-establishing healthy gut flora.
Before resorting to antibiotics, I would try a period of time with a grain-free, very low-carb diet (< 30g/day) combined with an increase in probiotic intake and HCL w/pepsin supplements. It's important to proceed slowly as you increase the probiotics, because moving too fast can cause gas, bloating and intestinal discomfort.
What’s your take on digestive enzymes supplements?
They can be helpful for short-term use, but ultimately acidifying the chyme in the stomach (via HCL supplementation) should produce the same effects and save you $$.
One more thing: there is evidence that raw milk can prevent asthma from developing in children. I haven’t seen any studies on whether it can actually treat or cure asthma, but it’s certainly possible.
Very good article.
My acid reflux (very bad even at a young age) seemed to get worse during times in my life when (i) I weight lifted and (ii) drank a lot of beer. Weight lifting can cause IAP as does the bloating from beer (and maybe some carb malabsorption too).
I’ve considered going very low carb to avoid reflux but I think the other health costs weigh against it (but that’s another whole conversation).
Thanks for your very thoughtful essay.
Great article. I have a lot of questions :)
Except medicine, what can cause low stomach acid? I know there are people who had GERD but hadn’t taken any meds. Could it be low levels of minerals, proteins, fats? Or is it perhaps the bacterial overgrowth itself?
How do one test for low stomach acid?
I have a relative with GERD. The reflux happens when she drinks coffee. Do the bacteria like coffee? What other non-carb intense foods can cause reflux and why does this happen?
well written. I imagine that there is incredible variability in how each of our guts responds to different diets. Big protein meals for supper have always made me sleep poorly.
Tim,
Bacterial overgrowth can cause hypochlorhydria, especially h. pylori. It’s estimated that more than 50% of people in the world are infected with h. pylori, so that’s probably the primary cause aside from PPI use. Studies indicate that h. pylori infection increases with age and is the cause of higher rates of hypochlorhydria in the elderly.
The medical test for low stomach acid is called the Heidelberg capsule test. It’s a small plastic capsule with measuring equipment that is swallowed and monitored via radio.
The “low-tech” way of testing stomach acid, which I’ll describe in the article on treatment, is to do an HCL challenge test. You take a 200 mg capsule of HCL w/pepsin before a meal. If you notice no burning, you increase to two capsules the next meal. Proceed until you notice a mild burning sensation, then immediately reduce your dose to the number of capsules that preceded the burning or heat sensation.
If one or two capsules causes burning, you either don’t have low stomach acid or your reflux is so severe that you won’t be able to take HCL until you get it under control. NOTE: do not perform this test if you have an active ulcer or a history of ulcer.
The bacteria don’t like coffee, but if she has milk and sugar in it they love that. Coffee is high in tannins, which can cause indigestion.
Tooearly,
When stomach acid is insufficient, putrefaction of protein can cause gas and increased intra-adbominal pressure. This could certainly affect your sleep. It’s possible your stomach acid is low or borderline low, and you’re not able to digest large amounts of protein.
admin: gas and pressure, eh? I went off Aciphex today. I’ve been on a very low-carb/hi-fat/hi-protein diet, and have felt tremendous pressure all along the lower rib cage (upper colon?) especially on my right side for the past week or so, have been farting like a tuba quartet and haven’t taken a crap in a week. Maybe going off Aciphex will hopefully knock something loose.
Forty2,
My guess is your stomach acid is extremely low from the Aciphex. Try taking HCL w/pepsin capsules before meals. You might also try slowly increasing your intake of fermented foods (yogurt, kefir, raw sauerkraut, kombucha, etc.) to address the bacterial overgrowth. Constipation is almost always related to an insufficiency of healthy flora in the gut, which can also cause all of the other symptoms you describe.
Awesome article, Chris, and excellent explanations and references!
Thanks Mike!
Admin: I drink kombucha daily and some days I eat full-fat “Fage” yogurt as I did this morning right out of the container. There’s a jar of Bubbe’s fermented raw pickles in the fridge I keep forgetting about.
Do PPIs have a permanent effect? I’m loathe to try HCL supplements at this point. Psychologically, I suppose, but I don’t ever want to revisit the searing pain of reflux ever again.
Forty2,
The effect is probably not permanent. However, there have been some reports that taking Prilosec can lead to achlorydia that can last more than two years after discontinuing the drugs. I completely understand your reluctance to try HCL. However, if it is low stomach acid that is causing your digestive problems, which seems likely, HCL could have a profound effect. Just make sure to take only 200 mg to start with, and do it before a meal. I’ve had several patients that have experienced remarkable results with HCL after years of heartburn and GERD.
OK, if the burn returns I’ll pick up some 200mg HCL/pepsin thingies. So far, so good, but it’s only been 24hrs since I took the last Aciphex. I *hate* taking any sort of medication so getting off the PPIs would be a big win.
We spent the last two years making dietary changes. The SCD seems to work great for us and now I’m looking into “fine tuning”. It’s funny/lucky, or however you want to put it, that your recent topics are covering things I have wanted to know more about, especially acupuncture and this. My son spent his first 8 mos of life on Zantec, so I have often wondered about this. I wonder if HCL could improve digestion. Is there a way to ask a doctor to check a small child for this?
I really enjoy the information and your writing style is great, easy to understand. I really appreciate all of this.
Hi everyone,
I’ve just published Part III of the series. This was an unplanned article based on a study I just came across yesterday that provides further evidence that GERD is caused by bacterial overgrowth, and examines the connection between GERD and H. pylori.
Enjoy!
Chris, I’m curious…
What does spicy food have to do with it? Do you know why it is that people experience more GERD symptoms when eating spicy foods?
Also curious about the FOS connection. Does that imply that FOS makes gas and heartburn worse?
Thanks for taking the time to put together all this info.
Sarah,
Spicy foods are often rated on surveys as among the worst culprits, but studies don’t actually support that notion. It’s difficult to isolate variables because nobody eats hot spices by themselves. They’re always eaten with food, and in many cases that food contains other ingredients like industrial vegetable oils and preservatives (i.e. kung pao chicken) that could irritate the stomach.
In some cases I suppose the spices alone could irritate the gastric lining, especially if someone has an ulcer or chronic stress has inhibited prostaglandin production and their mucosal barrier is compromised. But in that case it’s not the spicy food that is the problem – it just exacerbates the underlying condition.
what about salicylate intolerance? – spices are really high in sals
Oops, forgot to answer your question about FOS.
Yes, I think FOS will increase gas and heartburn in people with bacterial overgrowth. However, the question is whether this effect is temporary, as the bacterial flora in the gut rebalance, or ongoing. I don’t know the answer to that question.
Hi folks,
The next installment in the series is up: How your acid stopping drug is making you sick (Part A). Part B will be published on Monday or Tuesday.
Enjoy!
Very nice article, Chris. That’s why drinking apple cider vinegar has been a popular home remedy for acid-reflux, for the reasons you explained. (2-3 teaspoon, with water if you feel it is too strong. It is good for blood stagnation type of chest pain too, even if it is not caused by heartburn)
Great series! After taking prilosec for over a year, my wife persuaded me that after having been on a low-carb diet for about the last 6 months of that time, my problem may well be gone. It was! Have had maybe a half dozen instances since (all due to overeating just prior to bed, and involved an abnormaly large carb intake). I used to have that many instances a week!
Smart wife! Aren’t you glad you listened to her?
Final article in the series is up.
Also, the entire series as well as recommendations for books and offsite articles can be found here.
How long does it usually take for some relief to start when using HCL and eating low-carb? My symptoms are a constant burning in my upper esophagus and throat. Will it take time for that to go away as my body heals, or should it go away as immediately?
Everyone’s different. For some relief is relatively immediate, others it takes a bit of time. Either way, it’s worth it!
Hi Chris,
I have been reading your very informative blog for a while, first found it through the podcast about fish oils. I see you are yet another advocate of a low carb diet. From everything i read here and everywhere it seems like all my problems (hypoglycemia, heartburn weight gain etc) should be cured by a low carb diet but in reality I didn’t experience any of these problems until after the first time I tried a low carb diet. Every time I lower my carbs (am trying to lose 10lbs right now) I have gas, heartburn, hypoglycemia, mood swings, weight gain etc. I think it is from the healthy fats in the fish and olive oil on the veggies so the obvious answer would be to switch back to higher carbs but I am fearful because of everything i read suggests the opposite. I did go to the dr but they really seem to do more harm than good which is what brings me here.
Amanda: problems with fat digestion are often caused by a sluggish gall bladder and/or low stomach acid. The fats in the fish and the olive oil wouldn’t be responsible for hypoglycemia, mood swings or weight gain. Try supplementing with ox bile and betaine HCL with pepsin right at the start of meals. That should help.
thank you! will order some HCL for the heartburn and keep reading for the other stuff
Do you know much about gastroparesis? I saw that it could also present with my same symptoms, but I don’t know how common it is. I sometimes get heartburn, nausea(less frequently and not necessarily after eating),bloating and belching after a meal, and sometimes it comes or continues up until a few hours after I’ve ate! Are those symptoms still a normal case of indigestion/ low stomach acid? Everything started after I had a course of antibiotics with prednisone. First was the gastritis, which started out as major belching, then ended up burning badly, which I went on Prilosec for. I also have bowel troubles sometimes. I’m worried of rushing into something and somehow making myself worse. In your opinion, should I be worried about another cause?
Brittany,
Your symptoms are what they call “non-specific”, which means they could be caused by any number of things. Based on your history (i.e. they started after antibiotics & steroids), my guess is they’re due to intestinal dysbiosis. Both antiobiotics and steroids have a profound impact on the gut flora. Dysregulated gut flora can cause IBS, IBD, GERD and several other digestive conditions. The “three R” therapy I described in my GERD articles would still apply as a general strategy, but you may want to seek out help from someone familiar with treating GI problems with natural approaches. I use a stool or breath test for H. pylori. I’m not certain of the accuracy of the blood tests.
In your summary – reduce bacteria AND limit carbs. Yes I live on fiber carbs for IBS/constipation prone and dairy for osteoporosis and recently have really started bloating and having gas. I’m a senior citizen who now has time to eat and I enjoy it and hate taking pills. I’ve always been convinced that what we eat makes us sick and what we eat will make us well. If it’s not carbs does that just leave meat?? And how do we reduce the bacteria? I take a lot of GAS X and every morning I take a Jarrodophilus with FOS capsule. I also test “allergic” to brewer’s yeast and baker’s yeast which none of the Dr.s I go to recognize. I need a Holistic, Geriatric Physican that specializes in diet. Thanks for your help.
The natural human diet is high in saturated fats (65%), relatively low in carbs (20%) and moderate in protein (15%). So, yes, meat and traditional fats make up the bulk of calories, but by weight ends up being 60% plants (starchy tubers, fruits, berries & veggies) and 40% animal foods (fatty meats, seafood, eggs, healthy fats). You reduce the bacteria by reducing the carbohydrate content, and by consuming fermented foods.
I have been diagnosed with GERD, and, through an endoscopy, was told that I have a small hiatal hernia. Isn’t that a structural issue that prevents the LES from functioning properly? Is there anyway, other than medication, that I can manage my reflux?
I bet people note spicy food on surveys because the reflux is that much more painful. The one time I saw a digestive disease doctor (who was useless) I completely gave him the bitchface when he suggested not eating spicy foods. I make very spicy foods at home and I already knew that raw jalapeno and crushed red hot peppers, etc, did not exacerbate my symptoms. I’m glad the science has borne that out.
The one exception is when I had an active ulcer. OW!!
Btw, Doc, since I had a prior H. pylori infection (which the doctors I went to would not give me antibiotics for–I thought antibiotics were standard of care?–though they did waste my money on a “magic 8 ball says ‘results murky’” gall bladder ultrasound), should I undergo a course of antibiotics? My digestion has been slowly deteriorating and I finally cut out wheat/barley/rye and all but small amounts of un-nixtamalized maize (i.e. corn meal) from my diet. (To clarify, I am eating nixtamalized maize, aka masa, products, such as tortillas. They go down like butter!) This did 86 the GERD symptoms (less than a week–much faster than Prilosec), but you have me worried about my acid production.
I came across several studies which show that there exists an unbuffered layer of “acid pocket” post meals which could be responsible for reflux symptoms. Here are the links:
http://www.ncbi.nlm.nih.gov/pubmed/11606490
http://gut.bmj.com/content/57/3/285.extract
Here is a latest one done last year:
http://www.ncbi.nlm.nih.gov/pubmed/19651625
If these findings are true then, woudnt increasing stomach acid be a bad idea? since the problem may not be related to low stomach?
Shyam
Chris,
What about hiatal hernias as a cause for GERD? What is the current information you have about this?
Great article, Chris. As a Nutritional Therapist, I’ve found starting people on jsut a low carb diet (or in some cases just removing gluten) often reduces symtpoms of heartburn and GERD. If things don’t improve or improve only mildly, I’ll then bring in the HCl. No need to supplement if diet alone can take care of the problem!
Hi I just joined your email list.
A friend told me about taking vinegar before a meal, I started out doing it before every meal, for a few days.
Now I am doing it before Breakfast and Dinner.
Which is the right way or am I completely wrong in both ways.
I work at a Health food store as Cashier. And a friend told me to take Papaya Tabs when I get the heart burn in between, and it has also helped me.
I was taking the Meds for about 7 to 10 years, and I am determined to not take any more, altho they did work for me and after finding out what they do to your body, I really want to quit them.
Any Help you can give me will sure be appreciated. Thank you so much, Rosalyn
Make sure to check out all of the articles in this series: http://chriskresser.com/heartburn
Thank you I am in the middle of trying to read this stuff.
It is a lot to read. But I have learnt a couple of things already.
Always eat Bubbies–Kombucha we sell and tried it, Yuk, but I will try to drink it again–We sell DGL.
I will get some of the Herbs, and try 5 drops in water. How often should that be a day.
Thank you so very much Rosayn
I have hit a Road Block.
I have High Blood Presure and was told by Karen that is in charge of the Suppliment Isle at the store where I work, that I shouldn’t really take the DGLs as it may put up the BP.
Is that right??? Nd if so what sould I do go back to doing the Vinegar befor eating.????
Thanks Rosalyn
Rosalyn, I hope it’s not too late to reply to your question about DGL. It is SAFE to take. It does NOT raise blood pressure. The reason it is safe is because the natural licorice has been “denatured” to remove the substance that causes the kidneys to retain water and thereby raise blood pressure. (Notice that DGL stands for DE-Glycyrrhizinated Licorice.) If you’re still not convinced, do a Google search on DGL.
I always keep a bottle on hand.
All the best,
Pat
Hi Kris!
I First want to say, I enjoyed reading your articles and hope to try some of your changes soon. My case seems to be a little different and thought you may be able to provide some insight. Had an upper endoscopy three years ago which resulted in diagnosis of Gerd and Hitias Hernia. Tried a variety of medications. Was still having other symptoms to include chest discomfort, belching, gas etc. Recently had a 24 hour PH Probe test done as well as motility on esophogus. I was taking Prevacid twice a day prior to test. Test revealed that despite me taking medication I still had higher than normal acid as well as bile reflux? I was told to up my dose of Prevacid. I haven’t noticed any changes since the increase in dosage. Additionally I recently had bloodwork done to show enemia and low vit D. My gastro now wants to do another endoscopy to biobsy for allergies or celiac? My questions are, since I seem to have higher acid and not lower, is it still possible to have the bacteria that is causing the preasure or maybe the bile? Secondly is there any correlation between celiac and acid reflux or esophogeal issues that you are aware of?
Hello Chris,
Thank you very much for the very informative article!
It would be great to get your suggestions on how to increase stomach acidity (besides following the low carb diet).
I find that raw milk, vitamin C and ground mustard seeds work really well for me, but I can’t really take them with each meal. I’d like to stay away from the HCI supplements if possible.
Any thoughts?
Thanks,
Beth
Hi Chris
I loved your article. It is simply great. I want to learn more about alternatives medicine now.
I have acid reflux. I want to learn more about I started having it when I was about 30 years old and had frequent heartburn. I did few treatments with drugs that doctors prescribed me but it never worked so I started taking omeprazol on my own. It has kept my heartburn away but I am having too much bloating and my bowel movement is not good. I have taken it for about 2 years. I did an endoscopy last month and my doctor said my esophagus lining was fine and he recommended me to continue with omeprazol. I try to eat healthy as possible but before I started taking the anti acid it made very hard for me to eat. If I had garlic, for example it made sick. I was afraid to eat. I did not know that carbohydrates were the food to avoid until now. In the brochure that my doctor gave me it says that I should avoid acidic foods, fattening foods, and caffeine and dairy. I tested for the H. Pylori a year ago and came negative. So I am going to stop the anti acid now because I know I damaging myself with it. Do you have any suggestions besides decreasing my carbohydrates intake. I eat my carbohydrates more from fruits, legumes, leafy vegetables and whole wheat products.
Hi Chris
I just wanted to let you know I am doing much better on the Acid Reflux, and Haven’t taken any of the Meds since I started taking the Vinegar in the a,m and the DGL and spices that you recomended to me.
I am soooo thankfull for your Great Advice.
Waiting to read #3 in this subject. Keep them coming.
Many Many Thanks Rosalyn
THEY HAVE SAID THAT WITH A SCOPE THAT MY VOCAL CORDS ARE SWALLEN AND MY TONSILETS –I HAVE HAD MY TONSILS OUT WHEN I WAS 12 – NOT SURE WHAT TONSILETS ARE. I AM A SINGER AND HAVE NOT BEEN ABLE TO SING FOR MANY YEARS DUE TO CLEARING OF THE THROAT, AND SWELLING LIKE IN THE THROAT WHEN DOING SO. I USUALLY DON’T HAVE HEART BURN WHERE YOU CAN FEEL IT, BUT ONCE IN A WHILE DO HAVE THE REFLUX THAT LETS FLUID COME UP INTO THROAT AND MOUTH. sO DOES THIS SOUND LIKE (GERD) AND WHAT MIGHT I HAVE TO DO TO STOP THIS.
JUDY L.
I was plagued by indigestion and gas for a number of years before the serious reflux symptoms started. I’ll never forget the first time I felt that violent, stabbing pain. For a couple weeks I was afraid to eat – especially in public for fear the pain would strike and I’d be buckled over, unable to control myself.
My doctor prescribed Tagamet, which I took before every meal for months.
In 2003 I went on a low carb diet for weight loss (I was about 50 lbs overweight), and at some point along the way I ran out of Tagamet. I ate rather cautiously for a few days but felt pretty good. Intrigued, I bought more Tagamet but decided I’d wait to take it until I experienced symptoms. I never opened the box of Tagamet, and threw it away a couple years later.
It’s been 8 years now and my GERD has never come back. I still eat moderately low carb most of he time. I always attributed the disappearance of my GERD to low carb but never knew for sure. It all makes perfect sense now!
Hi Chris,
I have been suffering with Acid Reflux very badly since the summer, but last year had to take Ferrous iron as I was anaemic. Do you think that low stomach acid might have been the cause of the anaemia? I had a colonoscopy and all was fine there and was tested for Coeliac disease and that was fine, so they decided that my periods must be heavy. I think that they were wrong!
I am quite worried about it now, as I wonder what other nutrients I have not been absorbing. I have read Dr.Wrights book with great interest, and as I live in England (where H2, PPI’s are also given out like sweeties) there is no way to have your stomach acid levels assessed, the Heidelberg capsule is not used by UK doctors. (I emailed Heidelberg to find out!). So I decided to take the plunge and start taking Betaine HCL with Pepsin – after being prescribed by the doctors one lot of omeprazole for 2 weeks and one lot of Zantac (about a month later), both of which made me feel worse. Also I am following Dr.Wrights ideas by supplementing with vitamins, DGL before eating and am about to start taking digestive enzymes too. I have ordered an organic kefir starter kit to start to encourage the good bacteria. However, I am definitely feeling quite unwell (was before the HCL) and am still having some reflux and heartburn. I am very thin already and am worried about reducing carboydrates as I am worried that I will lose more weight. I am taking on average 5-6 HCL capsules (648mg) with every meal. If I take them towards the start of the meal I have no burning or warming sensation at all. My tongue is coated with white and I am generally feeling very exhausted, with huge bags under my eyes! I am nearly 47 years old and feel about 80. Last year I was very fit, a ten mile a week runner who only realised my iron levels were low when I lost all stamina. On the 16th December I am having an endoscopy to look at the esophagus but feel that this will only make my doctors say “You need acid blocking drugs” when I am sure the reason is otherwise. I have been on 5/6 capsules for a week, and the previous week worked up from one to two to three etc over the period of that week. I have stopped at 5/6 as Dr. Wright recommends that 5-7 seems to be the optimum number. I know that I am only 2 weeks in, but is there any idea how long it will take to kick in? I think my reflux is slightly lessened which is good, and the belching is lessened but still not gone. My lower guts seem to have given up and I am very constipated which is a nightmare. I would be very grateful if you could give me an idea of which carbohydrates to avoid..are all veg and fruit alright to eat? I’m a little muddled and more than a little sorry for myself! Thank you.
Yes, HCL (stomach acid) is required for iron absorption, so low stomach acid can certainly cause anemia. Restricting carbohydrates (of all types) to less than 50g for a period of time can be helpful.
Thank you, I will continue with the HCL Pepsin and cut down the carbohydrate..and stop with any grains, try and introduce good bacteria. I notice that you advocate a Paleo approach to diet, funnily enough I had started to embark on this when the reflux started – maybe a sign that the low acid in my stomach just was not able to cope with the higher levels of protein were introduced? Thank you for all your invaluable advice, it is great to hear a voice that is looking at ALL the evidence to provide answers, rather than following the conventional medicines route of PPI’s and acid blockers.
Hi, I have absolutely been put through the ringer. I was having throat pain almost 6 months ago. To make a short story of the affair I went through a normal doctor, an ENT, and finally a GI. I have been given a z-pac, antihistamines, prilosec, prevacid, carafate, gaviscon, In that order. I had burped a few times before this ordeal and food would come up. I never really thought about it till the throat problems.I had loose stools from time to time (ate lots of cereal, fats (cheese), carbs (bread), and popcorn) also I always get sick from eating really greasy or sugary food (runs in the family) but otherwise no pain or bloating etc. After being put on these meds I can’t eat more than a bite without feeling nauseous, bloated, etc. I had been having gas for a few days that smelled absolutely rotten from both ends (It is embarrassing however I have never produced anything that rancid before). I felt mildly normal while on the last set of meds (gaviscon and carafate) until I stopped taking them to gauge the rebound effect and it is excruciating. One of these two meds is what has caused the smelly death farts and what I assume is gas pain and/or acid burning from the food in my stomach putrefying. The gas and continued stomach upset are what finally prompted me to disregard my doctors advice. So now I am taking something called ‘probiotic multi-enzyme by nature valley’ and it is chocked full of enzymes: Calcium 144mg, Phosphorus 110mg, Betaine Hydrochloride 100mg, Pancreatin 100mg, Amalase 50 mg, Protease (papaya extract)50mg, Bromelain (600GDU per gram) 25mg, Papain (papaya extract) 25mg, Pepsin 25mg, Ox Bile25mg, Lipase 25mg, Cellulase25mg, Lactobacillus Acidophilus 1 billion. The death gas is gone but otherwise I am not noticing any immediate relief upon taking these enzymes. I have been on them for a little over three days. I want to take more HCL on its own but my stomach constantly HAS a burning sensation, I don’t want to take more than I should (if I even need it) but I am having trouble coming up with a way to gauge the burn. Endoscopy no ulcers, negative for H. Pylori. I am also leaning toward a possibility of food intolerance.
Hi Chris,
41 year old male. No major health issues. I have never had any issues with heartburn until last Monday, November 28, 2011. Shortly after dinner I noticed I had a little heartburn afterwards. I went to gym 3 hours later and still had the heart burn. Now, 5 days later I still have it. Last night, in the evening the heart burn went completely away until I awoke today when it came back after dinner. Can acid reflux come on that quick? My stomach is sour. Looser than normal stool. And occasional burps. Before I found this site I was thinking I might have some type of stomach bacteria or virus? My father has a hiatus hernia which he has had for years. And my fathers sister has the same condition. I was a heavy Red Bull drinker for a year. But I stopped drinking them about 3 months ago. Not sure if that could be related or not.
Chris I had one other though. A long shot but I thought I would ask. My nephew recently had mono. And I was reading how Esophagitis can be caused from Herpes. Now mono is in the Herpes family, correct? Is it possible I contracted a strain of the mono virus from my nephew which is not attacking my Esophagus?
I don’t have any food coming back up. No vomiting or nauseousness. No weird tastes in my mouth. Just heartburn sensations, sour stomach occasionally. And sometimes a sore throat when I eat.
Hi, Chris thank you very much!
I’ve suffered from GERD for years without relieve from conventional drugs (PPI & antacids). From your articles I am able to put almost all puzzle pieces about GERD’s causes, symptoms, & treatment in its place after years of researching.
But one thing still isn’t resolved. It’s hunger sensation, which constantly afflict many GERD sufferers including me .
Is it caused by excess gas in guts and stomach? Thanks.
Great article, I really enjoyed it! My husband experienced terrible GERD for his entire adult life until he started taking Prilosec. It seemed like magic. But what was truly magical is that he didn’t “need” Prilosec once he switched to a low-carb, paleo diet.
I am 7 1/2 months pregnant and suddenly have terrible GERD 24/7. I follow the diet in the Healthy Baby Code, consuming lots of raw milk, egg yolks, pastured meats, etc. and avoiding food toxins. It is no mystery what is causing pressure in my abdomen, but I was wondering if you have any suggestions on remedies that are safe during pregnancy. I do not have any gas or other digestive issues, just GERD. I’ve thought about trying the apple cider vinegar but I want to confirm that it is safe during pregnancy. Any tips would be greatly appreciated! Also, it might be a great addition to the reference material in the Healthy Baby Code.
Hello Chris, thank you so much for these article series — they really are a life saver for me!
I do have two questions though:
1) What do you recommend to eat for breakfast? I seem to have zero stomach acid early in the day and I find that paleo foods, in fact any meat/fish, first thing in the morning does not digest at all.
2) This question is related to the first one. I am breastfeeding right now and was told I cannot take HCl by my doctor as well as my lactation consultant. I have tried ACV, lemon juice, fennel seed, raw sauerkraut, probiotics, DigestGold, but I can’t seem to raise my stomach acid sufficiently. I have taken HCl a couple of times and it made me feel fantastic, but since I can’t take it for now, is there anything else you can suggest? Fats do seem to help a bit (coconut oil, butter, bacon grease), but I don’t always have access to these foods at every meal, but breakfast is the most problematic. Please help!
Thanks!
Jean
Hi Chris,
I’m a mom of a one year old that has had suspected reflux and possible milk protein intolerence since she was 2-3 months old. She’s been on zantac and now Nexium (currently 15mg in the morning). I HATE that she has been on these meds. She has had constipation problems and still has suspected reflux symptoms on and off. She can’t talk so it’s hard to ever really know what’s going on but she has never been a good sleeper and is always being woken up in the middle of the night by something and then often can’t return to sleep. After reading all of your articles, I’m more determined than ever to get her off of the meds. Any suggesstions for a 1 year old on weaning and how to manage the reflux symptoms she may still have from an underdeveloped anatomy?
i’m a female age 30 years and have never had a good stomach, recentley i have had a very difficult time, that started with an Iron Deficiency and weight loss.I was put on Iron theapy but was malabsorbing so was referred to a gastro and had a gastroscopy and colonoscopy to see what was happening, the gastroscopy showed that i had 50+ ulcers in my stomach !!!! I was put on 40mg of Nexium a day to heal them, the gastroenterologist was astounded i had no gastro symptoms of the ulcers at all. I have been fine for just over a year, i’ve put weight and started to feel more healthy, untill just before Christmas when i started with reflux, i thought i had a throat infection to start with because my throat was sore and i had a horrid taste in my mouth, my GP tried various combinations of things, none of which seemed to help. Over the course of Christmas i came to the conclusion it may be caused by lactose intolerance so i canged my diet and it went well for a week or so and then started up again although the lactose free diet seems to have cured the bloating.I feel constantly sick and its really starting to get me down. I thought i must have had loads of acid otherwise what caused all the ulcers, because they still dont know, i was tested for zollinger ellisons and it wasnt that. Any thoughts welcome
I had problems with daily acid reflux for more than 15 years, until a few years ago when I was diagnosed with hiatal hernia…My doctor was “assuring” me that there is very good medicine for this(proton pump inhibitors ) that I will have to take all my life. I didn’t really accepted that a physiological deformation can’t be fixed, so I started to do some googling… After I tried a few things, including abdominal massage and some speciffic physical exercises the most effective way to reduce my acid reflux was by losing weight! I lost weight using a low carb diet inspired by the Atkins diet, but not that brutal…I’m basicaly cured from my chronic acid reflux and free from any medicine. I’m really glad that I discovered this website and this article and now I’m making sens of how negatively refined carbs affects digestion. I just wish that more people with similar problems would find out about this “cure”…! Thanks!
Chris, do you feel that paleo diet is best for someone with polycystic kidney disease? Eating paleo does help my reflux and does raise my stomach acid, but eating low protein alkaline diet seems better for my kidneys. I’m really confused. Thanks for your input!
So glad I found your website! I have been on Fluticasone Propionate Nasal Spray, Symbicort inhaler and then had a Kenalog Injection (all corticorteriods Triaminolone Acetonide) for allergies. Now do I have stomach and intestine problems. Gas, bloating, constipation, stomach gurgles bad (especially at night) sometimes indigestion. I feel like a wreck! What should I do??Thanks!
Hi
I did have the acid test and i do have low acid but when i take hcl it makes the problem worse! I have small bowel bacterial overgrowth.
Why would i feel worse?
WOW
I am profoundly grateful and impressed by your article. I have suffered from a “weak” LAS for years and this is the first article I have read that emanates deep study, good sense and intelligence.. Congrats!
I’ve been taking 20 mg of Omeprazol daily for about 10 years (I’m 40 now) and I really want to stop taking it. I tested negative for Pilory and my concern is if I stop taking Omeprazole, even if I don’t show gerd symptoms, I’ll have a high risk of cancer of the esophagus because of the sphincter. I know this med causes side effects, specially with bones (osteoporosis?), so shall I risk going off it?
Thanks for your article!!!!
Very elegant demonstration.
Just to understand clearly : the increase in intra-abdominal pressure occurs because of too much H2 in the gut, which then compresses the stomach, which pushes acid into the oesophagus. Is that correct?
Hello,
I am having frequent sore throats.I think this might be because of the acid refux.Please suggest what to do?
Is it safe to take HCL when pregnant..I had amazing results before I got pregnant, but am reading a lot about questioning the safety when pregnant..I am taking 150 mg tablets 3 x’s per day..thanks!
Please let me know where I can find out more information and more articles from Chris Kresser.
Great article. I had just forwarded it to my husband to read since he is the one who has this occasional heartburn, a couple days a week.
I do have a question about this. His heartburn is kind of predictable, it depends on what he eats first thing in the morning… If he drinks tea with honey, he’ll get one and it’ll last all day long. Or a bowl of soup for example, basically almost any liquid meal/drink will cause it. Except coffee though, maybe because he has that cup after his hearty breakfast of eggs. Why would his body have a heartburn after tea or soup but not after coffee or any other ‘heavy’ food. He is overweight and I always thought it was because of the pressure as explained in this article. OH and he loves his carbs. I would love to hear your thoughts on this!
Thank you! I’m not new to all this info but am new to your site
With the honey I would have said that it’s feeding the bad gut bacteria that are contributing to the gas and pressure against the LES, but that doesn’t make sense with soup. Perhaps he’s sensitive to the free glutamate in the soup broth and the tanins in the tea.
I stumbled across your website today and it’s really great. I ended up here through an extensive Google search trying to figure out why I am extremely bloated, constipated (I go maybe once a day or every other day but I feel like it’s not all getting out–or maybe I’m filled with gas, although I’m not able to pass it often), and never really feel hungry. When it’s time to eat I already feel full within a bite or two!
I think through your info the lightbulb is starting to go on…several years ago I had a couple episodes of food regurgitating back into my throat, lots of burping, and a burning sensation at the top of my chest. Never having experienced that before I went to the doctor and they sent me to a specialist for an endoscopy. I was in my late twenties at the time and 40 pounds heavier–I ate horribly and hardly ever had whole fruits and veggies.
They told me I had a mild case of GERD, said to avoid mint, chocolate, caffeine, and fatty foods, and prescribed Aciphex which I took for about 3 years. Now that I am wiser and trying to eat well, I wonder why they just didn’t send me to a nutritionist and make changes there! Three years into taking the Aciphex, I started having noticeable lower right abdominal discomfort. I had a hernia ruled out at the time. So I stopped taking the Aciphex against the advice of the specialist who told me to also take Citrucel for my ab pain, which he thought was just constipation. I felt sick taking the Citrucel so I stopped.
Between then and now, I discovered I had a wheat allergy—possibly Celiac—and they recommended another endoscopy. I said I didn’t want another one so I just started eating as if I were Celiac and as a result I’ve felt SO good and dropped 40 pounds. However, for the past few months the right abdominal discomfort is back and sometimes almost painful, but it comes and goes and so I think it’s intestinal.
Sorry for the life report, but after all that—do you think that even after all this time I might have hypochlorhydria and could benefit from the HCL? It’s been especially worse since in the last few weeks I have been eating more fiber to ease what I think is the constipation because of the ab pain and also lower back pain on the right side (not the spine, but muscle area). Once I stopped the Aciphex, added more veggies and fruit, stopped the wheat and stayed away from the mint, chocolate, caffeine, and fatty foods I have not had a SINGLE case of acid reflux symptoms in all this time. I just feel so bloated, gassy, and full but can’t seem to find relief. I tried one of those Activia yogurts today and two slices worth of lemon juice…it felt a little better…but??? Would wine at dinner help? Or grapes?
Thank you, Chris!
I am grateful that you published an extensive & thorough discussion about acid reflux and GERD. It’s very enlightening and informative.
I was diagnosed of acid reflux 6 years ago and I’m still suffering from it until now. It frequently occurs at the middle of the night. When it attacks I also have heart palpitation. What is the relation of reflux to palpitation?
I hope you could help me with this.
Thank you very much. God bless.
Chris
Nice summary of the current research (2 years after your posting)! Provocative way of looking at GERD. I wanted to clarify one point in your article: the studies on erythromycin improving GERD symptoms you cited were pointing to the immediate improvement of symptoms following IV administration of e-mycin pre-meals. They were postulating the prokinetic and direct effects on LES tone that e-mycin has, rather than the antibiotic treating SIBO, per se.
That said, antibiotics are indeed used for treating SIBO, but the symptoms usually take longer than the above mentioned studies report for resolution. Here is an article talking about e-mycin (and antibiotics in general) being used for SIBO/IBS:
http://www.ncbi.nlm.nih.gov/pubmed/20574504
http://www.ncbi.nlm.nih.gov/pubmed/2028847
Thanks again!