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.
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.
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We’ve Been Asking the Wrong Question
In an editorial published in the journal Gastroenterology, the author remarked: (1)
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).
For example, several studies have indicated an association between obesity and GERD, and one paper in Gastroenterology concluded that increased intra-abdominal pressure was the causative mechanism. (2, 3) 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
In his excellent book, Heartburn Cured, microbiologist Dr. Norm Robillard argues that carbohydrate malabsorption leads to bacterial overgrowth, resulting in IAP which drives reflux. Dr. Robillard makes a strong case that carbohydrate malabsorption plays a significant role in IAP, and I agree. But as I researched this issue I couldn’t help asking: what might be causing the carbohydrate malabsorption in the first place, and are there any other causes of bacterial overgrowth that may precede carbohydrate malabsorption? I believe the one answer to both of those questions is low stomach acid. Low stomach acid can contribute to both bacterial overgrowth (independently of carbohydrate intake) and carbohydrate malabsorption, as I describe below. In a nutshell, the process looks like this: Let’s look at each step in turn.
1. Low Stomach Acid Causes Bacterial Overgrowth
As I 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. (4) 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. (5) Eleven of the 30 Prilosec-treated people had developed significant bacterial overgrowth, compared with only one of the 10 people in the control group.
2. 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.
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Bacterial Overgrowth + Maldigested Carbohydrates = GAS!
In Hearburn Cured, Dr. Robillard points out that 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. From Dr. Robillard’s book:
According to Suarez and Levitt (17), 30 g of carbohydrate that escapes absorption in a day could produce more than 10,000 mL (ten liters) of hydrogen gas. That is a huge amount of gas!
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.
Other Supporting Evidence
Dr. Robillard also argues that if gas produced by microbial fermentation of carbohydrates causes acid reflux, we might expect that reflux could be treated by either:
- Reducing bacterial overgrowth, or
- Reducing carbohydrate intake.
He points to two studies which demonstrate this. In a study by Pehl, administration of erythromycin (an antibiotic) significantly decreased esophageal reflux. (6)
In another study by Pennathur, erythromycin strengthened the defective lower esophageal sphincter in patients with acid reflux. (7) 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. (8) A more recent study found that a very low-carb diet decreased distal esophagus acid exposure and improved the symptoms of GERD. (9) Perhaps most importantly, the magnitude of the improvement was similar to what has been reported with treatment with proton-pump inhibitors (acid suppressing drugs).
Some researchers now believe that Irritable Bowel Syndrome (IBS) is caused by small intestinal bacterial overgrowth (SIBO). (10) A study performed at the GI Motility Center in Los Angeles in 2002 found that 71 percent of GERD patients tested positive for IBS—double the percentage seen in non-GERD patients being examined. (11) 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.
Final Comments
To summarize, low stomach acid contributes to bacterial overgrowth in the bowel which in turn can lead to carbohydrate malabsorption (due to decreased pancreatic enzyme secretion). Malabsorption of carbohydrates, as Dr. Robillard has pointed out, increases intra-abdominal pressure and causes GERD.
Where Dr. Robillard and I differ is that I believe low stomach acid is the primary problem with GERD, with carbohydrate malabsorption playing a secondary role. I do think that improper digestion of proteins can, in fact, lead to GERD, whereas Dr. Robillard states in his book that putrefaction of proteins is more likely to cause flatulence. This may be so in most cases, but I’ve seen several patients in my practice on very-low-carbohydrate diets who still experience heartburn, which improves upon restoring proper stomach acid secretion (which we covered in another article in this series). 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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Try a parasite cleanse. Honestly, I did one and it make a HUGE difference. I did one with a tincture and capsules, but I had a friend (who is also an acupuncturist) recommend doing the cleanse homoeopathically (Heel is the brand that I found). Try to stay off gluten — and really any carbs if you can. I found that I have no bloating when I do that. Good luck.
Hi. I would like to ask if anyone has ever linked Gerd, heartburn, excessive acid reflux etc with taking any kind of mind altering drug. I took a ‘new wonder drug’ in 2000 when it first came over to England and it nearly killed me. I wasn’t the only one that suffered the many and various side effects from it. I later found it was a wolf in sheep’s clothing and was first made as anti depressant then used for whatever they felt fitting at the time. To cut a long story short, it jiggered my mind up from the3rd tablet and I was no longer in charge of my own mind. At the time I hadn’t realised that everything had shut down and I wasn’t functioning, and I hadn’t opened my bowels for at least 14 days. For almost 5 years I was no more than a shell, my young daughters dressed and fed me and I was best left staring at the wallpaper at home. I have suffered terrible stomach problems since that fateful day of starting the course of tablets. Intolerances of various foods, massive weight gain but only as a massive spare tyre on my midrift that is such a burden to live with. I was told I has irritable bowel then I hadn’t, cameras both up and down but nothing found. Liver scans show fatty liver but I’ve never been a drinker nor a person that favours sweet sugary stuff. I did later find out that other sufferers of this same drug had managed to find evidence of the fact that we were overdosing on these drugs because our livers were not processing them and getting rid so building up so technically overdosing. I’ve tried everything that I possible can to help myself. Cutting out foods one by one, apple cider vinegar, no cake or bad carbs and can say nothing has helped. I take omeprazole daily and pay for it if I happen to miss one and drink antacid med in sheer desperation when I’m having a particular bad do. I’m at the end of my tether, sleepless nights, sat upright to sleep, some days wind in my tum that doubles me up with pain, eat then fall into a coma like state, I take note of that food but it never seems to be the same food twice. The burning bad taste of bile that constantly comes up is soooo vile and after a bad night I’m afraid to try to sleep then next night, I need to be awake for when it creeps up on me! 14 yrs of this from what I’m convinced was started by my mind being altered by my chemical functions being messed with, this was the nature of the tablet to stop smoking, I have thought of suicide many times. Has anyone anything to offer to help me or any similar experience from drug taking. Thank you.
Maybe a natural Doctor Homeopathy may work for you, it is a little expensive like $100 dollars a session but once a month until it gets cure will be worth to try
Hi Ann. For a break I would suggest fasting. For immediate relief. Nothing but water for 24 hours. I would suggest also to take bitters or apple cider vinegar immediately before meals, to strengthen stomach acid. i would also suggest avoiding processed foods. Do you experience bloating? You probably have parasites and need to do a parasite cleanse (try hulda clarks, wormwood, clove oil and black walnut hull tincture in a specific combination, just google: dr hulda clarks parasite cleanse for details). When we take toxic chemicals into our body, like heavy metals or even those questionable drugs you were put on, it is too much for our bodies to deal with. Our bodies become weak. In a last ditch effort to stay alive, the body will sometimes create conditions optimal for the parasites to grow and gobble up the toxins. But, the parasites and the toxins both tax on our health. You need to eliminate the parasites and figure out what was in those pills, then follow some sort of cleansing system if possible. After the cleanse, eating fermented foods and foods that kill parasites will help. I just noted that you said you had wind in your tummy. To counter this immediately, eat kimchi. You must eat kimchi every day or every two days to keep away the bloating. If you cannot get that, try to find sauerkraut or something else rich in prolific bacteria (yoghurt has too much sugar and doesnt work). Good luck.
Ann,
you seem to describe my condition. sleepless nights, sleeping upright, depression, anxiety, suicidal thoughts. sheer desparation. medical doctors treat me like i am nuts (maybe true!) dont take my complaints seriously. tried to lose weight many times. do well for a few weeks but the pain in the stomach gets severe again and cant sustain the effort. very depressing, i dont like what i have become but do not see any hope. doc wants to increase PPI intake i think the PPI’s are the cause of the mental issues and dont think i should take more PPI. I have severe anxiety, nightmares. did not have this until 3 months after starting PPI. it is almost 3 years now and I now cant get off that PPI.
Hi Ann,
I went through similar feelings, I was even signed off with anxiety / depression but I don’t like to think of myself as depressive.
At about the same time, i was having issues with digestion and acid reflux and extreme hunger straight after eating. I looked on the internet and purchased Premier HCL & Betaine and noticed relief from the first dose. I also take a little sauerkraut with my evening meal (it does the same job as the HCL, but is cheaper and a real food). I also cut back a little on my water intake as too much can further dilute what little stomach acid one has. Low stomach acid can be caused by hypothyroidism and hypothyroidism can cause low stomach acid. I also suffer from hypothyroidism. I think by improving your digestion, you will improve your absorption and thus improve the hypothyroid condition (hopefully). For the anxiety and depression, I took aurum metallicum 30C. I cannot tell you what a difference that made, its almost like Im a different person. I am still on my journey to deal with the hypothyroidism but am seeing a glimmer of hope.
Hope this works for you too.
Your liver may be the cause of your basic health issues. Go to the Liver Doctor (Dr Sandra Cabot) website and you can call their US office. a healthy liver will process toxins, increase energy, reduce weight. They will investigate everything.
hiya
im UK too hun.am on antidepressants too, mostly for anxiety. my probs started when pregnant .
my liver constantly shows problems but they dont know why. i have to take Ranititide i think its called. 75mg. or the substitiute zantac. i have to take it twice a day, id like more but it doesnt advise it. my heartburn/acid burns my tonsils and roof of my mouth aswell as esophagus and its getting me down. weird thing is……if i have a chinese, im fine!!!! have you tried ranititide hun? im know looking into all this as no one is helping me!!!
im gonna try low carb diet, as protein helps me sooooooo very much. also am looking into herbal too.
good luck xxx
If stomach acid is low, you probably aren’t absorbing vitamin B12. Low B12 can cause a lot of the psychological symptoms you are experiencing. You can take it sublingually to get around poor stomach absorption issue.
I hope that you are feeling better.
PAT
May 2, 2014 at 5:35 am
I have the same symptoms, feeling of acid in my throat .
Dr Do you think that the HCL will work for met?
I had an endoscopy 2 years ago, the gastro said I have a small hiatal hernia,, but at that time, I only experience pain in my stomach and feeling of a lump in my throat, but I took Prilosec OTC and in time and relaxing it went away.
Now, I have had a lot of very stressful circumstances, and the acid before never went to my throat, and now it does!
Can you please help me? with any suggestions?
Thank you!
PAT
May 2, 2014 at 5:35 am
I have the same symptoms, feeling of acid in my throat .
Dear Dr Cris,
Do you think that the HCL will work for me?
I had an endoscopy 2 years ago, the gastro said I have a small hiatal hernia,he said that just watch what I eat and raise my bed, but at that time, I only experienced some pain in my stomach and a feeling of a lump in my throat, but I took Prilosec OTC for a short and I relaxed my inside guts and my abdomen muscles and got distracted doing other things, and with time and it always went away.
What I did Then and now is that I also noticed that I always have my stomach muscles very tight, and my shoulders and back muscles also, So I am trying to relax them and specially the muscles in my stomach , abdomen , and inside guts, ( it is a continual struggle, because my muscles are always tight)and it seems like when I relax them has helped me, I do not feel the acid as much. and specially when I relax my inside guts and abdomen muscles , I feel better.
Now, I have had a lot of very stressful circumstances, and the acid before never went to my throat, and now it does!
I reduced the 40 mg of omeprazol twice a day because the symptoms in my throat were worse!, I am trying to take my time to reduce it. Now I am taking zantac 150 mg twice a day, but for a couple of days I lower it to 75 mg and I did not see any difference.
Can you please help me? with any suggestions?
Thank you very much Dr Cris! Blessings.
POST EDITED
Ive heard going to a chiro. Helps with alot a symptoms with GI.
I had reflux for 20 years. the day I stopped eating bread it went away.
wow!!!!
def gonna do low carb and no bread. this has been a life line for me
Great articles. Very informative. I too am fed up with modern medicine. went to the doctors with gastritis symptoms, was put on PPIs, stopped after 4 days because of intestinal pain and got heartburn for the 1st time in my life! 2 months on and I can’t get rid of it. Docs keep trying to give me more PPIs and they make the gastritis and pain worse! I believe the gastritis is caused by food sitting in my stomach too long (probably due to low stomach acid) as that’s what it feels like after eating. I would like to know if anyone has tried apple cider vinegar or hcl tablets with gastritis? I already have burning in the stomach after eating from bile reflux. Would digestive enzymes be safer to try for a few weeks before starting the hcl? If anyone has any experience of this I would very much appreciate some advice.
try papaya enzymes-walmart!!
I suspect that ppi medications gave me ulcerative colitis which led to my colon being removed.
My hippie father told me those drugs would destroy my guts but I didn’t listen. I openly admit that I no longer trust moder medicine, it took 7 years of different doctors to figure out I had a basic ulcer. Then upon treatment I got here, which upon treatment I got ulcerative colitis. If I could go back in time I would have left moder medicine out of the equation completely.
Upon treatment I got gerd (not here).
I have been having severe hunger pains and I have IBS. I had a endoscope done and just a small hital hernia. I was taking 40mg of prilosec but it’s not working. What do you recommend me to take to kills these hunger pains. Thanks
Plz suggest me some diet for high stomach acid.
I am so happy I have found this site..I am a fifty year old women who has never had reflux issues until I started taking aPrevacid for gastritis. After five days on the Prevacid I skipped a day and a half of taking it and had the worse heartburn, regurgitation and reflux..I thought i was having a heart attack. I called my doctor the next day and she said to increase the dosage of the prevacid. Which I did, then I developed a lump in my throat, right in the center of my neck. Ihad a sore throat and felt like pills were getting stuck. I called my doc again, she referred me to an ENT who stuckma scope up my nose and said I have LPR. He switched me to prilosec. The prilosec seemed to make the reflux worse, after a week on the that he switched me back to the prevacid. I had a few good days once switching but this morning when I had a glass of water to take the prevacid, I could literally feel the acid coming up my throat..I am not sure how much more of this I can do this..what should I do..
I am so sleep deprived at present from my gerd symptoms that I can barely make sense of these articles. I want to implement these tools so badly. I have changed eating habits and am loosing weight. I just desperately need support to treat myself other than the PPIs. Any encouraging words would be appreciated. Thanks
You are not alone, Gwen, as you will see from the number of comments on this post. My experience is that there are as many “cures” as there are people suffering, you have to just experiment and find what’s right for you. I’ve started a blog (I’m sure there are many) to catalogue my own attempts at relieving my symptoms / finding a cure – I’d very much like to share experiences. howtogetridofacidreflux.info
Can I seek your advice on Usana Essetials I believe symptoms started since I tried to take this vitamins daily.
Hello,
I have lately been coughing whenever I eat, and feeling like a lot of mucus and my nose being stuffy. I cannot tell if this happened after I had a really bad diarrhea a few weeks ago and then started taking probiotics.
However, the doctor said it is GERD and put me on Nexium 40 once a day, Mozart 5, 3 times a day and an allergy medication once at night.
But, I’m very thin, don’t smoke or drink alcohol, and drink 2 small cups of coffee a day nothing more.. and don’t eat much fatty stuff and I dont have no heartburn.
I only started this treatment yesterday but my symptoms are still there.
I’m only 26 and it’s worrying me because I don’t want to end up having cancer, or having to deal with this for ever.
Can probiotics be the reason? or the diarrhea itself? or what?
Is there a way to deal with this without medication? I’m too thin and i don’t want to keep having medication because my body doesn’t do well with it, since i would probably have candida.
Any help is much appreciated!
(Sorry if this has been dealt with earlier! But I started read the posts, however they are a bit too long so I’m still in the early stages of it, but im impatient since im really scared now… especially since im to get married in a few months too, and probably will get pregnant right away, so don’t want to have to deal with medications by that time either!)
and to add something, lately i have been waking up with very puffy eyes, and need a bit to be able to open them fully.
can this also eb related?
I have to ask what your idea of a carbohydrate is? Most people assume that carbohydrates are the breads, flours, pasta, etc. But I know people who have gotten rid of their GERD by going on a raw food diet, which is a high carbohydrate diet. Its just a different form of carbohydrates, one our body is build to know how to process and use. Our bodies were never meant to process bread and pasta. So, for the purpose of this article when you said high carbohydrate, did you mean the breads and pastas??
high carbs usually refers to breads, potatoes, most grains, some beans and obviously cakes, cookies, etc..
Hi Chris,
Thanks for the article. I am 32 and just recently started battling GERD, LPR and gastritis. Initially I had a minor swollen lingual tonsil. ENTs prescribe antibiotics and mild steroids. Stress and those combined drugs brought on gastritis and made the reflux worse. I am having a heck of time trying to increase HCL with gastritis. I was getting better and got food poisoning. I then discovered I tested high for candida and started a candida diet with a 3 day fast which also flared up the gastritis. I have a high potency of DGL (from a herbalist). It works great. I am also using bitters, but I want to know if you think they are effective enough. I have read online some people are supplementing up to 3g or more of HCL. I have tried 1g and the bitters and my stomach seems to handle it. Yet I am unsure if it is enough. I have lost 30lbs in the last 6 months, and I am just under my normal weight so I can’t afford to lose anymore. Any suggestions for diet, maintaining weight and getting rid of these awful symptoms would be appreciated.
Thanks,
Kevin
It seems that in recent years, acid reflux/gerd/disgestion problems have become epidemic. I developed what I believe is silent reflux-24/7 (no heartburn, just tons of throat issues and often nausea in the mornings) around 2 years ago. Had a scope and do not have h-Pylori nor a hiatal hernia. Since that time, I’ve noticed that all my 6 kids, ages 11 through 26, have developed digestive issues and/or acid reflux symptoms as well. What the heck is going on in this world? Is there any way to know for sure? Is it GMO’s? Five years ago, I didn’t know anyone with digestive issues. Now, almost everyone I know or talk to, either has problems themselves, or knows someone who does. There are so many different theories on this discussion on cures. I am glad for those who have overcome it. I guess I will just have to trial/error it to see what helps me.
Hi Chris,
I’ve been on a ketogenic diet (75% fat, 20% protein, 5% carb) for a month now. I have developed this feeling of having a lump in my throat. It occasionally makes me belch, but it’s not really heartburn. I went to a GP and she said I should go on Prilosec. I’d rather not, with all the things I’ve read about it. And I’m not even convinced that it is GERD. They did an x-ray and that did not uncover any issues.
Might this be GERD even though I don’t regurgitate stomach acid, and do you think trying HCL is a good approach in my case? Perhaps it’s the keto diet causing issues and I should change that in some way?
Thanks!
-Joe
Hi Joe,
I’m not a doctor, but I have some experience with acid reflux and various treatments. In Chinese medicine, the lump in your throat sensation often comes from liver qi stagnation, which may be what’s going on, and the high fat diet may indeed be contributing to your discomfort. I’d recommend that you back off the high fat and eat more green leafy veggies, beets, daikon radish and wheat grass, occasionally. I would seek alternative treatments from a good practitioner of Chinese Medicine than take any kind of acid reducing medicine, which could potentially make your problem worse. I hope you feel better.
I was just wondering how exactly spicy food leads to an increase in abdominal pressure?
I also noted the mention of spicy or fatty foods causing an increase in abdominal pressure. I theorize that if I don’ have enough liquid already, then I drink more liquids with my meal, and the liquids dilute my stomach acid, raising the pH. I also note that liquids have a lot of volume, and that the my stomach is only big enough to handle a big meal. When I add liquid at mealtime, my stomach can’t hold it all. A lot of drinks, including fruit juices, have a lot of sugar carbohydrates.
Hi,
I haven’t heard any mention of mastic gum on this site. For the people diagnosed with h. Pylori, Mastic gum really helped me with my symptoms from h. Pylori. And it has relieved gerd symptoms in my 15 year old son. Another good addition is bone broth. It helps with improving and healing your intestinal lining. Try it.
J-
Hi, I have had burning stomach for 40 years and it is getting worse. The bacteria idea makes sense to me. For twenty some years I have had fungus in my left leg with occasional break out of rash that started in the toe nails and kept going higher and higher until it is completely to the top of my left leg. I have wondering if that could contribute to the bacteria growth. Maybe what they call candida. Would probiotics help. The opening area to the esophagus was too small and the doctors stretched it. I was having a hard time swallowing and many times food would get stuck there and I would have to bring it back up and start my meal over again. Some times I feel like I should not eat for some time in order for the condition to heal. The doctor is now concerned with cancer and I am headed for another check up.
Hi chris. I have had problems for 5 years. I get gas bloating, burp and have foul smelling gases a lot and heartburn after everything I eat. I seem to hiccup a lot after food too. Seem to be bad with coffee nuts bananas bfast bars peanut butter etc. The heartburn really hurts. Doctors said it was gerd. I had oesophagus burning. The doctor then said it was in my head or that I eat too healthy, eat too much protein and go the gym too much. The ppis seem to make it worse. I have been off and on them for the five years. I tried hcl but got burning straight away. Not sure what to do.. can u help.
Could be bile reflux. I had burping, gas for a year, then developed into painful gastritis, and they found bile in the stomach on an endoscopy. Also I’ve read elsewhere that hcl can cause burning the first time if your stomach is inflamed from gastritis. This is the position I’m now in, need to take something to speed up digestion in the stomach, but don’t want to risk the hcl with an already inflamed stomach lining.