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Heartburn, also called gastroesophageal reflux disease (GERD), is the most common digestive disorder in the US, and the acid-suppressing drugs used to treat it can have dangerous side effects after long-term use.
The prevailing belief by the public, and even many conventional doctors, is that reflux is caused by having too much stomach acid, hence the standard treatment with antacids and PPIs. But we now know that GERD is not a disease of excess stomach acid, and many GERD patients actually produce lower levels of stomach acid than normal.
In light of this evidence, it seems logical that heartburn must be caused by stomach acid inappropriately entering the esophagus. And indeed, tests for esophageal acid contact time have confirmed that most patients with heartburn and GERD do have above-normal acid contact time over a 24 hour period. (1)
As I’ve discussed in the past, one cause of increased acid reflux into the esophagus is dysfunction of the lower esophageal sphincter (LES), a valve that separates the esophagus from the stomach. This dysfunction can be caused by increased intra-abdominal pressure, which often results from bacterial overgrowth in the small intestine. This has been one of the prevailing theories about the underlying cause of reflux for several years now, but it has some limitations.
Not All GERD Patients Have Abnormal Amounts of Acid Reaching Their Esophagus
As I just mentioned, most GERD patients do have above-normal acid contact time. But most is not all. In fact, 24-hour acid contact tests have found that up to 30% of GERD patients actually have normal acid contact time. (2, 3)
Some patients with GERD symptoms even have normal endoscopy results – their esophagus looks the same as a healthy person’s esophagus. These patients are considered to have ‘non-erosive reflux disease,’ or NERD, and up to half of NERD patients have normal acid contact time. (4)
So, what separates a healthy individual from a GERD or NERD patient with normal acid contact time? If there isn’t too much stomach acid reaching the esophagus, what is causing the heartburn?
One theory gaining traction in the scientific community to describe this phenomenon is the idea of impaired epithelial barrier function. In other words – GERD might be a result of “leaky esophagus.”
Is a “leaky esophagus” the cause of your acid reflux? #gerd #heartburn
What Is “Leaky Esophagus”?
You’ve probably heard of “leaky gut” before. Cells in the epithelial lining of the intestine are held together by tight junctions, and if these tight junctions are disrupted, particles that wouldn’t normally be absorbed make their way through the lining of the intestine and into the bloodstream. This can cause a host of problems, from food allergies to autoimmunity and more.
“Leaky esophagus” is a similar concept. It’s actually normal for acid and stomach contents to reflux into the esophagus occasionally. (5) In a healthy esophagus, this acid can’t penetrate the cell membrane of the epithelial cells, and tight junctions prevent it from getting in between the cells.
In fact, normal esophageal tissue is remarkably resistant to acid. In acid perfusion (or “Bernstein”) tests, acid is dripped directly onto the esophagus through a tube that is inserted through the nose (sounds pleasant, right?), and healthy people don’t experience any pain or heartburn, even after half an hour. (6)
However, if those tight junctions are disrupted, acid can make its way between the epithelial cells, decreasing the pH of the intercellular space. Since even small pH changes in this area are threatening to the body, there are pain receptors located close to the epithelial lining, and they send pain signals to the brain in response to the lower pH. These signals are interpreted by the brain as heartburn. Unsurprisingly, patients with NERD or GERD who receive the Bernstein test experience discomfort almost immediately.
As further evidence of the presence of leaky esophagus, biopsies of GERD and NERD patients almost always reveal dilated intercellular spaces, which is a marker for impaired barrier function. (7) These dilated spaces are increasingly being accepted as a hallmark symptom of both NERD and GERD.
Is Leaky Esophagus a Cause or a Symptom of Reflux?
It appears that leaky esophagus is present in most cases of GERD. But it’s not clear whether leaky esophagus is a cause of reflux, or just another side effect.
Even though a healthy esophagus is resistant to acid, high levels of acid exposure over time will eventually lead to inflammation and impaired barrier function. In this case, increased acid exposure comes first – most likely due to a dysfunctional LES – and leaky esophagus is not the root cause; it’s just another symptom.
However, there maybe some reverse causality, particularly in GERD patients who have normal acid contact time. In this case, something other than acid exposure disrupts the epithelial tight junctions, which causes heartburn even at normal acid levels. Over time, this “leaky esophagus” can lead to the visible epithelial tissue damage observed in GERD patients.
This happens because the “back” side of an epithelial cell is not as resistant to acid as the “front” is, so once the acid seeps through the tight junctions, it can enter cells from the back and cause cell death and tissue damage. (8)
Unfortunately, this process can actually lead to LES malfunction and increased acid exposure, creating a vicious cycle. Now, increased acid exposure in the esophagus is a symptom of GERD, rather than the root cause.
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What Causes Leaky Esophagus?
So if leaky esophagus happens first in some cases of GERD, what causes leaky esophagus in the first place?
One possibility lies in the esophageal microbiome. The esophagus houses a community of microbiota similar in complexity to the intestinal microbiome, and the makeup of this bacterial community is different in healthy people compared to people with GERD. The microbes found in the esophagus of GERD patients are primarily gram-negative, while the microbes in the esophagus of healthy people are primarily gram-positive. (9)
Increased numbers of gram-negative bacteria can trigger inflammation by exposing epithelial cells to lipopolysaccharides (LPS), a component of gram-negative bacteria that causes immune responses in the body. (10) The inflammatory cytokines released in response to LPS can then lead to loss of tight-junction integrity, resulting in esophageal permeability. (11, 12)
Exposure to LPS can also cause the LES to relax, promoting reflux and increasing acid exposure time – again, creating a vicious cycle. (13)
Unfortunately, there isn’t a lot of research yet that clarifies the causes of increased esophageal permeability. But if the mechanisms at work in the esophagus are similar to those in the intestines, other probable causes could be stress, excessive alcohol consumption, and excessive use of non-steroidal anti-inflammatory drugs (NSAIDS). (14, 15, 16, 17)
All of these factors can contribute to leaky gut, so it wouldn’t be surprising if they contributed to leaky esophagus as well.
What Does This Mean for Heartburn Sufferers?
As you can see, GERD is a complex and multifaceted disorder with no single cause or presentation. Luckily, all of the strategies for healing heartburn and GERD that I’ve been recommending for years would also be expected to heal leaky esophagus.
A low-carb Paleo diet, gut-healing foods like bone broth and fermented foods, regular stress-management, and a focus on balancing the intestinal (and esophageal) microbiome with probiotics and prebiotic foods are always good approaches to treating the root cause of GERD.
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Hello,
Is this forum still active? I would need an advice.
I think I already have an ulcer (a mild one), and I have the biggest problem when laying down in the night. I immediately feel the acid, and feel my stomach and heart working hard “to do something”. I usually drink a little bit of lemonade and it helps to sleep. But I know lemon is not the best if it is really an ulcer.
Could you help what should I do before meals or after meals, or before going to sleep to leave acid behind, and be able to sleep well?
I already take aloe vera before meals, and I am also eating bananas.
Thank you,
Julia
It’s been four years since coming off of PPI’s and it’s been a journey to wellness to say the least. It’s been extremely difficult for me to get a proper diagnosis of my condition because I have a hiatal hernia. Once a doctor sees you have a hiatal hernia, then that is all they treat; either through PPI’s or surgery. Surgery seemed like such a drastic solution without exhausting every other treatment.
Anecdotal evidence through the speaking with people directly, websites such as Chris Kresser’s, books and trial and error is the way I have attacked the problem.
Most recently, I did a couple of cleanses; one for parasites and the other for yeast. Part of the yeast cleanse suggested taking colostrum for 90 days after the cleanse. Now in the last 1/3 of the 90 days of colostrum, I’m starting to see results. Remarkable results. At least for me they are remarkable because I haven’t had to take HCL with pepsin which has been my go-to remedy for the last two years, at least.
Norman Robillard’s book Heartburn Cured sent me in the direction of looking at bacterial overgrowth fuel by carbohydrates as the culprit. That is what led me to the cleanses and eventually the colostrum to heal my gut lining.
It’s still early days, but I feel better than I have felt in a number of years. I would encourage anyone with GERD to look into the benefits of colostrum. From the literature, I can see no bad side-effects.
Good luck.
I have years of chronic cough and reflux. Chriss Kresser has provided an outstanding analysis and posible help. But previously I have been following work by Jamie Koufman, MD.
The works are well documented with extensive references and patient outcomes in these two books.
Quick study and solutions: Dropping acid…….
http://www.amazon.com/gp/product/0982708319?psc=1&redirect=true&ref_=oh_aui_detailpage_o00_s00
The detailed analytical book: Chronic cough enigma……….
http://www.amazon.com/gp/product/1940561000?psc=1&redirect=true&ref_=oh_aui_detailpage_o01_s00
I hope some will review these, they were helpful to me.
Hi Chris I am currently being investigated for possible bowel cancer due to extreme abdominal pain, loss of bowel control, bloating, inability to eat a full meal, indigestion etc.
However, my Brother-in-law has had very similar symptoms. I realised that he, like me, has suffered from GERD from a young age and has spent almost a lifetime using ant-acids. in particular Rantidine.
I am convinced that my symprtoms are a result of using ant-acids. I have a family history of GERD my grandmother had stomach ulcers, my mother suffered from GERD, I had refulx as a baby and GERD my whole life.
I am also concerned that the GERD and the treatment of it through ant-acids may have affected my family in other ways.
My maternal grandfather died of Bowel cancer before he was 40, my grandmother had stomach cancer along with stomach ulcers and my mother has Lupus.
I am very concerned also about my daughter, she is 4 and suffered from reflux from birth which was controlled with Gaviscon. She has not had any ant-acids since being approx 2 but she is constantly burbing and complaining of stomach ache and so i feel she may be suffering from GERD again. I am loath to take her to doctors as I suspect they will push for me to give her ant-acids. Something I am not willing to do. I have ordered all the recommended supplements for myself but want to know if these are suitable for a 4 year old too?
As regards to the possible damage i have due to Rantidine is it reversable? I have stopped taking rantidine, last one on mondy, and the GERD isn’t too bad at the moment although to be fair i’m not eating much at the moment so that could be controlling it.
I am very worried.
You need to look up Autoimmune Protocol Diet and you and your daughter start that…it’s very tough, BUT very much worth it…I’m healing after 4 months and feel completely wonderful! Just hang in there! My son sounds a lot like your daughter and fyi he’s starting the AIP diet very soon!
Maybe it’s ulceration due to consumption of low levels of corrosive hydrofluosilicic acid called fluoride in drinking water? Boiling water or cooking concentrates this substance in our beverages and foods. It is highly corrosive to esophagus. Read MSDS Hydrofluosliicic acid from Mosaic. The MSDS states that it works with a delayed reaction.
Interesting. I have been taking a proton pump inhibitor for 7 years following gastric bypass surgery. If I miss more than 2 doses of the PPI, then there is significant pain in the epigastrium. Since my anatomy is different, are these suggestions something I can try?
It is overwhelming and yet comforting to read that so many people have similar medical stories. My GI doc is performing a scope to follow up on a previous Barrett’s Esophagus diagnosis. Are there any other procedures or tests he could perform at the same time that would be beneficial in diagnosing the causes of BE and GERD or is it only functional medicine tests reveal such problems?
I had GERD for many years sometimes better and sometime worse but always present and I took pepto and anything that would help. I finally realized that it was really gall bladder disease and had my gallbladder removed. It was better after that but returned because the cholesteral crystals cause a domino effect as they go from the liver down the sensitive bile duct. In 2012 there was an medical journal article which said that linolenic acid was very effective in disolving the crystals. I found the best source was evening primrose oil and finally got good relief. I believe now that it is all related to the not having enough good bacteria to eliminate the cause of the crystals.
First off I want to thank Chris Kresser and his site. I suffered from gerd, make that severe gerd for over 10 years. I think without Chris’s site and one other one I found by fluke I would be dead. My body was a wreck ! I couldn’t talk for over a month and couldn’t sleep for weeks. I had to take a clip board to talk to anyone by writing things down. I lsot so much weight on antacids The most important things that helped heal and cure my Gerd were:
1) Betaine HCL (lots of it) and getting off PPI’s. I still have to take 6 Betain HCL capsules with every meal. You need to make sure you take enough ! If you take to few of them they make your Gerd worse. The various sphincters in your upper digestive tract need a lot of acid to tell them to close. If there is not enough acid present they don’t close and gerd begins. It also restores proper acid levels in the gut to kill the bad bugs in there.
2) Melatonin ! I still take it. I have experimented without and my gerd is almost non existent with it. There was a scientific study done in Brazil I think about melantonin and gerd. Chris said he was going to do a psot about this one day.
3) Paleo low carb diet, especially at first to kill/starve the bad gas causing gut bacteria, fungus, yeast ect.
4) Things like timing of eating, angled bed and identifying trigger foods like chocolate or for me mint !
Again I want to thank Chris for his site and the info therein. Also the posts I found elsewhere on melatonin and taking more acid capsules if two to three make your gerd worse. Good luck to all you sufferers out there. I know how you feel.