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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.
Better supplementation. Fewer supplements.
Close the nutrient gap to feel and perform your best.
A daily stack of supplements designed to meet your most critical needs.
The last time I had what felt like severe heartburn turned out to be a heart attack.
Drinking water with some apple cider vinegar in it and staying away from wheat and tomato based products has helped me tremendously. I also had to cut back on my addiction to caffeine and pasta. I now pour out the first minute of brewing of my black tea and rebrew for relief of the acid reflux. I’m moving towards totally kicking the black tea to the curb. I heard white tea has much less caffeine. When I do indulge in pasta, I don’t do spaghetti sauce and only eat short pastas, no spaghetti. I’m having a hard time though keeping weight on. I already have a thin frame to begin with, but feel I’m turning into skin and bones. I want to include protein shakes in my diet, but don’t know what brands would be GERD friendly. Any suggestions Chris?
I highly recommend Dave Asprey’s Bulletproof whey protein and/or collagen. It’s tasteless and comes from grass fed cows with a full amino acid profile (precursor to the master anti-oxidant glutathione). Don’t add it to hot drinks or it may denature the protein. The collagen is great too. Also, check out Chris’s interview on Asprey’s pod cast… it’s what brought me to this site. Bone broths seem to help me a lot… peace to you!
Thank you for that info. I will look into that. 🙂
Hi Joy – Tea is one of my triggers too. I drink Rooibos now and have come to enjoy it.
Thank you. I’ll have to try the rooibos tea.
Lots of questions, not a lot of answers.
This is a great article. Several years ago I was diagnosed with GERD and given Protonix for over 9 months. Then I developed new issues and was diagnosed with SIBO. The GI doc wanted to give me anti-depressants and keep me on antacids.
I went to see an O.D. I went through food allergy diet and testing and had low hits to tons of foods I regularly eat, but nothing was a major offender. On a whim she suggested HCl. For the first time in years I felt better. It cured my gas and diarrhea and heartburn. I have been on HCl for about 3 years. Now I wish I could find a way to heal and produce my own acid.
What do you have patients do once they find out HCl works? Do I just stay on it forever to be able to digest proteins? I know it’s not supposed to help with fats, but it seems to help me with fatty foods too.
Having heart burn issues, weakness in the esophageal muscle (trouble swallowing), tightness in my chest at times with an ekg that freaked one doc out, but cardiologist said it was just inflammation. I am wondering if this is due to having a piece of food stuck in my throat over night (until I could get it removed by the G.I.)….years ago. Any suggestions? It’s obviously a LOT looser in my throat 🙁 33 years old now… seems that it’s just going to get worse.
I too have burning LES, not sure if it is GERD related or not, I do feel I have a problem with the functioning of my LES, when I lay on my right side I can feel it open up. I can have the burning even on a empty stomach. I had upper endoscopy last year and biopsies for H -Pylori and Celiac that were negative, pic too show no damage to Esophagus. I also have Geographic tongue, Burning tongue syndrome, adrenal fatigue, and have had H-Pylori overgrowth in the past. On top of all that I am 53 this year and perimenopausal….. Not sure what or where to go from here, I have been put through the ringer with conventional doctors and Alternative doctors with no help, every test under the sun!!
Sounds like you just need to heal your gut because you have all the related symptoms. Avoid grains and mostly eat Paleo (lots of veggies, little meat if at all, bone broth, pre and probiotics, fermented foods, no sugar or processed foods). Also, you might want to consider trying HCL with betaine. Good luck!
Thanks for your reply, I have been on a low carb paleo diet for a couple years, also autoimmune paleo, I am starting to think it has more to do with hormone fluctuations for me anyways. There are a few studies done on hormones and the functioning of the LES, especially low progesterone. The burning tongue and Geographic tongue are both syndromes and not one person on this planet knows what causes it, it’s very painful for me along with the heartburn. It could be that the LES burns the same as my mouth. Klonazapam for seizures, anxiety stops the pain messaging to the brain, it is one of the recommended treatments for burning mouth syndrome, but who wants to be hooked on benzo’s. I wish someone would figure it out.
Wow! reading your post is like looking in a mirror for me. I never thought about the burning geographic tongue as being a menopausal symptom, but it did start after my hysterectomy so it makes sense. It was getting really bad and then I started a low carb paleo diet a few weeks ago making sure I drink lots of fluids and it seems to have disappeared. Now I’m working on the GERD issue so I’m trying to limit my liquid intake so we’ll see how that goes. I also started on digestive enzymes, probiotics, DGL and now yesterday I started with HCL w/Pepsin. Seems to be working, but I can’t get rid of the pain in the middle of my back/chest. perhaps that may just take time from inflammation.
which tests did u get for h pylori? are you sure you eradicated it? its implicated in geo tongue
I had many issues with GERD for about 3 or four years. More than just heartburn, food was getting stuck at the end of my esophagus, especially on the first bite (steak or other firm food). I would literally jump up and down to get the food to pass into the stomach. Drinking fluids would increase the pain associated with the blockage, but it was sometimes necessary to add weight to the food to help it pass. The relief was to take Prilosec and remember to make the first bite at any meal a small one.
After switching to a primarily Paleo diet three years ago, I have not experienced any symptoms of GERD at all.
I recently been diagnosed with low iron, am getting infusions 1xweek. Since esophagus is a muscle could low iron contribute to nerd or undetected gerd as I was diagnosed with? Turkey tail has almost cleared it up plus low fruit, no fruit juice bowel detoxes and cleanses
Chris, if gerd is not caused by too much acid and not enough acid why do acid reducers work?
In cases where GERD is caused by a dysfunctional LES, some acid will get back into the esophagus (even if the stomach is only producing a small amount of acid)—and PPIs can suppress stomach acid production to almost zero, so they will help.
Fascinating comment on melatonin Chris. Any recommendation or info on dosing?
Read this study: http://www.medscape.com/viewarticle/717460_5
Some researchers recommend melatonin itself (3-6 mg at night), while others recommend melatonin precursors like 5-HTP (50-100 mg/d) or L-tryptophan.
How do you get traditional doctors to recognize these new studies? I am a veteran and use the va for my medical insurance. I have had a health issue which can be leaky esophagus since 2012 and do not have any answers to what it might be. I am always told I am in good health and have anxiety. please help
Don’t guess you’re lucky enough to be close to Iowa City, where VA Dr. Terry Wahls practices. She has a book using paleo diet/principles for m.s. (developed to reverse many of her m.s. symptoms), and other chronic diseases, that along with Chris’s wonderful website has helped practically eliminate my silent reflux that was causing throat closure making it hard to breathe. (I also get little help from regular or g.i. docs.)
Chris, I need to know if gabapentin can cause heartburn. I increased dosage to 1600 mg. a few months ago and since then I have started having terrible heartburn. I had an endoscopy about four years ago for GERD and it looked fine with just some redness. I am 55 and get concerned with knowing what the cause of the pain is. Tends to be mostly on the right side of chest, arm, and neck. Just wondering if the gabapentin could be the cause?
Hi I too have associated gabapentin with return of reflux. I wish I had never taken it but was in terrible pain from back spasm. Gabapentin relaxes things so it seems it relaxed my LES!
That is what I think but my doc says no it will not do that, just a co incidence that reflux returned at the same time as upping the dose of gabapentin . Hope you feel better soon.
I’m 78 and I believe I have lo stomach acid. It takes between 6 and 9 hrs for mystomach to empty, and even longer if I eat a large meal. I took PPIs for over 11 yrs with no relief. I was able to get off PPIs while on a 2 wk gut cleanse. Now I eat early in the evening and I have a small meal. Also I lie on my left side and do not have the burning symptoms.
Arlene,
Do you take Betaine HCL? That has been a huge help for me with my food digesting faster. That and digestive enzymes (and biles salts for my gallbladder issues.)
Hi Arlene – I have slow digestion too. I find that a couple of teaspoons of apple cider vinegar after a large meal helps to move things along. I believe that the pyloric sphincter relies on acidity levels, so perhaps ours need a little extra encouragement.
What if you have “Barrett’s esophagus”? Is it safe to stop taking a PPI?
Chris, I have a friend with same symptoms mentioned by some patients here. But what i was telling her is that she should check her bacteria in the stomach. I know and have heard quite a lot about the h pylori which triggers the stomach in different ways and this can be carried on for years if not attended. I know of others who have had the same stomach problems and have used the raw iris potato to cure it. Taking it in the mornings before breakfast. Hope this helps those persons who are still looking for a solution to their stomach ailment.
Estrellita
I was diagnosed with GERD a few years ago. After being prescribes Prevacid to take forever!, I researched and quit it. I got a bottle of Swedish Bitters, took it religiously until finished, and felt cured. In the past couple of years I’ve adopted a much healthier diet, to include glutamine. I’ve not had any serious problems again.
Janet,
Where does one find/purchase Swedish bitters?
What is the connection between this and someone who has bulimia?
Melatonin has worked for me. It apparently affects the LES
I was able to achieve the same results, Melatonin every night stopped all GERD symptoms…
What dosage of Melatonin do you take?
A google on: “GERD melatonin” shows the connection has been around for a while, but the melatonin dosage suggested in the medical literature is often high for melatonin, e.g. 3-6 mg. If less works just as well, then so much the better. A low starting dose of 0.5 mg melatonin is often suggested in relation to sleep, going up by 0.5 mg increments as needed to find a minimum effective dose, a maximum of 3-4 mg, with the idea that, with melatonin, “less is more”. In melatonin research, high amounts have often been used that are unnecessary and inappropriate for regular use.
I’d be interested to hear what melatonin dosage was used by people who claim it cured GERD.
Medscape on GERD-melatonin:
http://www.medscape.com/viewarticle/717460_5
Also, it’s possible that high night-time cortisol levels, late bedtimes, and evening/night lighting and computer screen viewing are contributing to low melatonin.
Any late night snacking on top of that can only aggravate a GERD problem.
Yes, it affects gastric emptying and LES tone. Helpful and relatively unknown treatment.
I have LPR.
To stay low carb Paleo do I need to eliminate plantains, etc?
Don’t prebiotics cause more abdominal pressure and worsen reflux?
It depends. Those with SIBO and similar gut issues tend to do better on low-carb or low-FODMAP diets until those issues are resolved. But after they are, adding prebiotics/fermentable fibers back into the diet as tolerated can help prevent recurrence.
I developed GERD being on healthy whole food moderate carb(max200 gr day), minimum grains diet for 5 years…
I had never experienced heartburn till 40, including 3 pregnancies.
But I had very intensive professional life, which I loved very much. The GERD started year after Lyme disease and 0.5 year after I started high fat (45-60 % ccal) raw diet(raw diary and egs included). So the potential causes could be long term stress or bacteria or too much fat for me?
Unfortunatelly low carb (below 50 gr/day) Paleo diet did not help me to stop terrible burning in chest and mouth (throat and dental gums were affected by inflamation also)! I felt some anxiety and inability to get to sleep then, therefore I increased the carbs.
By tests my GERD was caused by HH and non functioning LES, and I was operated.
Unfortunatelly, operation 3 months ago did not help either. I am in situation when nothing else left and in pain 2 years now.
Waiting patiently, as post op tests show no erosions in esophagus. Why the pain and throat and mouth inflamation then?
Microbes,inflamation, false pain receptors vicious circle?
I am folowing moderate carb approach (100 gr day) now, taking Prescript Assist, PPI only occasionally. Fermented giving me gas unfortunatelly.
I am begging you Chris pls advice what to do?
You might try the FODMAP diet .
I would see if you can get tested for SIBO, H. Pylori, and immune dysregulation with a functional medicine practitioner. Good luck!
Chris, Fascinating article. I’m experiencing the same symptoms – ie just had endoscope with normal appearance of esophagus, but continuing acid reflux with burning throat and mouth (i’m currently taking prednisolone which i understand makes acid reflux worse). Can you recommend functional doctor (or a list) in the UK?
Sorry, meant to click on notifications..
You might contact Dr. John Briffa in London. If he’s not accepting new patients, he might provide referrals. Zoe Harcombe might also be able to provide referrals.
If H pylori is present, what do you think of using high doses of olive leaf extract to eradicate it instead of the harsh antibiotics.? I have been on a non stop weight gain roller coaster for years after standard H pylori treatment.
Might LDN (Low-Dose Naltrexone Therapy) help with the effects of Lyme’s disease and the inflammation it causes for the patient Modesta?
Modesto,
Have you been over to SCDlifestyle.com? There is a huge amount of info and resources there! I had esophagus issues, leaky gut, digestion issues, bacterial infection, adrenal burnout, etc. I am doing the SCD diet and a found a functional medicine practitioner on the SCDlifestyle website. I am doing SO much better now! God is so good to have led me there! The intro diet listed in their book is crucial. I’m saying a prayer for you right now! I understand how uncomfortable these issues make life, but there is hope.