This is a guest post written by
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.
It’s going to be a complaint post 🙂
I have terrible GERD/NERD! To the point that for almost 2 months i wasn’t able to eat (just few bites a day), and i wasn’t able to sleep due to very severe bloated belly, burping, and the worst- heart palpitations accompanying all the symptoms. I really though I was going to die.
Symptoms go weaker for a while and now I feel it’s getting worse again.
What to do? 🙁
I’ve had 2 Xifaxan treatments (SIBO)- not much improvement, on the top of that i feel like probiotics worsen my symptoms. I’ve been on paloe diet for 1/2 a year- gradually keep feeling worse. Made changes in my lifestyle, eat lost of supplements. Won’t even begin counting out my other health issues and I’m only 33.
I feel like “gut” is the source/part of other issues. I’m at a loss what to do. What to do? Any recommendation? Are there specific probiotics that are better for that problem(I have histamine intolerance)?
Thanks a lot! Your website is very informative. Wish there were more educated physicians here , in Poland 😉
Aga, where did you test for SIBO in Poland? I am thinking about this, as in my country it is nowhere to test, doctors do not know about gerd/sibo connection.
Modesta
In Warsaw i would recommend PRIMA clinic, since their test last 3 hours, not 1 or 2 like in most clinics. You can also ask for either- lactulose and glucose test.
Aga, could you pls send me your contact to [email protected] in case I would need more info about SIBO testing in Poland/
Try MMS. You would be surprise what it can do it for you.
Learn what is MMS and how to use it. It is available in Poland but you really have check the sources you will get it from. I can recommend you some good place to buy if you want to. Or see which place Jim Humble recommend (founder of MMS).
Search MMS on google and learn. If you want to save time, just email me and I will send you the links for MMS (the truthfully links). If you Polish – you can wright to me in polish.
Look up aip diet…the autoimmune protocol diet….it will change your world…it’s not easy, but it’s so worth talking yourself into…I’ve been healing for 5 mons now…and I am a HUGE believer!!!! Good luck!
I was dxd with Gerd and HH after severe upper respiratory infection with deep coughing in 2000. Put on high dose ppi’s ate non processed food. Gerd turned into LPR with chronic throat clearing that had worsened over the years. Started having chest pain, that i misdxd as esophogeal spasms, and treated it with acupuncture and chiropractic. Long story short at age 54 i had to have emergency heart bypass surgery: the digestive pain was Unstable Angina! Then ended up with cancerous polyp probably caused by large dose PPIs.
Now at 66, off all meds since 2012 when i went paleo. I have to say nothing has helped, whether ive been on ketogenic diet or no grain etc, the LPR just keeps getting worse. Dxd with SIBO recently, and also, really low gut motility.
So,1) rule out heart stuff if you are having gastro pain
2) dont take ppis, 3) get checked for SIBO
Told by functional gastro to not drink bone broth with cartilage content, it feeds SIBO. Still figuring out what to eat. She said start to eat jasmine rice…..so confusing!
I totally agree with the recommendation to not eat bone broth. Bone broth has GAGs (glycosaminoglycans) from the cartilage it feeds the bacteria and can greatly increase GERD. For me it is a major trigger for GERD. You will also want to avoid cuts of meats that have bones in them and require a long time to cook. These are typically the tastiest cuts, like pork ribs, lamb chops or prime rib. I also find that pork skin (aka cracklin pork) gets me too.
I have done Rifaximin and herbal antibiotics on and off for the past 18 months and still no relief. I am about to do my third SIBO breath test, but I have very little hope that it is going to prove anything.
I think the leaky esophagus sounds like a reasonable theory. One day we are going to fully understand the relationship we have with bacteria and I believe that will put an end to so many of these chronic diseases. Too bad it has to be such a slow process.
I’ve taken the diet approach to reflux after seeing the image of my burned esophagus from a endoscopy. I take no scripts, no nsaids. If I stick to the following program, I’m symptom free. Hard part is sticking to it!!
Make Up –
high fat (1/3 animal fats 2/3 non animal from things like ghee, olives, avocado, nuts), medium protein, low carb
regarding dairy: eat lots of homemade yogurt but no cheese unless homemade (raw) or goat cheese
moderate citrus, chocolate (bittersweet only)
no grains, wheat, soy, moderate caffeine, no refined sugar or processed food, very limited alcohol (beer not wine or liquor).
Time –
if in pain upon waking eat oatmeal asap
raw juices before 3pm only
load up on carbs immediately after endurance sports
after 3pm carbs from veggies only (no fruit) – emphasis on soluble fiber veggies (low intake of non-soluble)
no food of any kind after 7pm
Amount and Combinations –
chew everything completely (break down food so acids in belly don’t have to)
fruit is always eaten alone (otherwise it ferments in the gut)
no liquids with meals (dilutes stomach acid needed to break down food)
if you drink alcohol (yeah that’s cheating) than dilute it with lots of water so it does not damage the gut too much
Supplements –
DGL Licorice enzymes
I don’t know if I had GERD a few weeks ago but I had episodes of just throwing up whatever I eat. I even tried just eating saltines and threw them up too. It stopped when I took some probiotic capsules. Since then, I haven’t had any vomiting.
For the people I’ve advised, the removal or reduction of alcohol has had a significant effect on GERD symptoms, likely due to gut biome damage. Beyond that, generally sound nutrition advice, like eating whole raw food sources, and cutting out processed foods, comes in a very close second for efficacy.
Thank you Chriss for the suggestion.
About H.Pylori – I tested in 2 weeks both by blood – positive and by stomach biopsy urease test – negative. Whom to trust?
internet indicates that blood test is least effective and what H.pylory living in esophagus, not stomach is uncommon.
I would like to ask Chriss to comment on other possible cause of GERD – the dysautonomia or autonomic nervous system dysfunction. That’s what my country doctors do – the just offer antidepresant or antianxiety pills if you still complain with GERD. I am afraid to make such experiments…
I am 76 years old. Diagnosed with hiatal hernia years ago and Gerd because of frequent vomiting after meals. Placed on PPIs for years. I decided to go cold turkey about 2 years ago because the logic of the treatment escaped me and I was beginning to have symptoms of malabsorption of nutrients. Going cold turkey was beyond painful. But the excess acid production explanation made no sense since apple cider vinegar helped.
After endoscopy because I was very anemic, diagnosed with Stage IV erosive gastritis, healing ulcers etc. Still refused to go back on PPIs as recommended.
Fast forward. Tried low carb, little sugar diet. Lost about 20 lbs. Ate more vegetables, more fermented foods, more home made yogurt with whole milk, more Szechuan food (i.e. lots of red hot peppers). Feeling ever so much better now. Have started taking a bit of Melatonin before sleep recently. I am convinced most of my problems are over. Now if I do have occasionally symptoms of heartburn don’t tough it out but take a Rennie (TM) chew tablet (like Tums but with both calcium and magnesium carbonate) and 40 mg of Fantomine. (i.e. an Histamine blocker not a PPI)
Also have become convinced that digestive issues are a continuum… (I have adult children diagnosed with colitis and with Crohns)… all are controlling their symptoms so far with diet and without intervention of huge amounts of Western legal drugs pushed by big Pharma since none of it seems to get at root causes while plastering over symptoms which then has deleterious side effects.
Am convinced that any efforts to re-equilibrate “naturally” and nutritionally and take responsibility for one’s own health can work. Website that make information generally available, like this one, are invaluable to that process. Thank you.
It is interesting you mention alcohol, but what about soda? Soda is fairly acidic and many people pretty much live on it. Also, will digestive enzymes help to improve this situation?
Pretty sure soda is the devil’s kiss of death for humans!
Interesting article, I actually have had acid reflux ever since I started the Paleo diet last October. I see a functional medicine doctor and we have had a really hard time getting my gut straightened out. I have never experienced any of these symptoms before I started Paleo. Amazingly my fibromyalgia symptoms have completely gone away so I am sticking to it but wish my stomach would calm down. Any suggestions? I eat a very clean strict diet!
Hi Kim,
It’s possible you might be having trouble digesting protein. Have you tried Betaine HCL with Pepsin and a good probiotic?
Take pancreatin, you’re consuming more fat and protein than you’re used to
My endoscopy showed major inflammation at the top of my stomach where it joins to my esophagus and had radiating redness. My gastroenterologist diagnosed my problem as “esophagitis.” I want to stop taking omeprazole twice a day!
Please help me figure out a natural cure. I’m not medically savvy. I would appreciate your help Dr. Kresser!
I took DGL and it really soothed my stomach, Then I started on digestive enzymes. I heard that we don’t have ENOUGH digestive enzymes and so our food rots in our stomach, creating lactic acid, which the acid reducers take care of. However, we don’t get all the nutrients from our food. It’s a vicious cycle. So I slowly increased the digestive enzymes and now I don’t have reflux any more. I made sure the digestive enzymes I took had HCL in them.
Also heartburn could be caused by a drug you are taking. I took the Rx Zanaflex which is a muscle relaxer and had terrible heartburn for days, could not figure it out, saw my Dr and she did not catch it either. Did a search for side effects and yes, that was one. Quit taking it and heartburn went away.
Chris, I had an endoscopy recently that showed polyps in the middle and lower third of my esophagus. Also erosive gastritis in the antrum and stomach body. I have been gluten free for over a month and only eat whole foods now. Can these heal like the gut with probiotics, bone broth and so on? I never use nsaids. I was asked to use ppi’s but they made it worse! Help!
Dr. Kresser,
Thank you very much for this information.
I have had really bad heartburn in recent years; I have also been struggling with candida overgrowth following a course of antibiotics. I’m 99% sure that the infections in my gut and esophagus are yeast rather than bad bacteria. (I had a stool analysis which showed yeast but no dysbiotic bacteria.)
Do the same principles apply to esophageal candida infections?
My understanding is that candida is gram positive, so I’m not sure if it would work the same way. But perhaps, as a pathogen, it still causes inflammation?
If you have any thoughts on this, I’d be most grateful. Thank you!
Hi Chris,
My symptoms are much more in line with gastritis (stomach pain, bloating, burping) than GERD. What do you advise to treat gastritis? I’ve had an endoscopy, and was told I have acid reflux. I took Prilosec for about 2 years and have been weening myself off for the last 6 months, and it is painful. I just started HCL with Pepsin 2 days ago and am lowering my carbs, but haven’t noticed too much yet. Any advice?
My extreme heartburn went away after I stopped eating gluten foods. It took about 6 weeks to heal, and bit of heartburn would creep up once in a while for several months, but now it is gone. Ten years of taking omeprazole and the problem, for me, was gluten all along.
My son was taking a low dose antibiotic for acne. He would take it at bedtime without water and then lay down. It wreaked havoc on his esophagus and he ended up sick for the majority of his senior year in high school. He had persistent GERD, inability to easily swallow, constant cough, asthma, pain. The feeling of not being able to breathe well gave him anxiety on top of everything else. Thank you for this explanation, it helps me to understand why this happened.
Hi Chris, I am quite surprised to read recommendations of melatonin and no warning on the risks and the potentially harmful side effects that have been observed on many users. Theses side effects include sleep disturbance, body’s circadian rhythms disturbance, mood changes, including irritability, worsening depression, sadness, stomach problems, including nausea, vomiting or stomach cramps. In addition to this, melatonin interfere with normal hormone levels such as estradiol, progesterone, luteinizing hormone, prolactin, cortisol and thyroid hormone. It is a huge market in North America and misinformation on the product leads to massive consumption, some kind of miracle self cure for many symptoms. Lot of reliable literature can be find on the topic. I also wonder why you don’t mention treatments and options for the ones suffering from an actual excess of acid stomach production, I would be interested in reading your recommendations in this matter. Best regards.
You’ll find more information and treatment recommendations in Chris’s free eBook on this topic:
http://my.chriskresser.com/ebook/heartburn-gerd/
Have been eating low carb paleo for last 16 mos but in last two months developed RUQpain leading to gall bladder tests (within normal range) and now after giving up my healthy fats eggs dairy I have GERD sxs of bloating nausea and occasional reflux while simultaneously feeling starving! I don’t know what type of diet alleviates all these sxs while leaving me full. I am normal weight middle aged female.
Chris….do you any insight into eosinophilic esophagitis?
I have had GERD for the last 15 years. I take prescription Omeprazole 20Mg once a day and it takes care of it. But I better not miss a couple of days as the symptoms will come back in a jiffy.
Do I create collateral damage?