Gastric / Stomach ulcers
GERD - "Heartburn"
GERD - NOT A PROBLEM OF TOO MUCH STOMACH
ACID, BUT RATHER NOT ENOUGH ACID
What is GERD?
GERD occurs when the stomach's acidic contents flow backward into the esophagus
(sometimes even reaching the mouth).
The esophagus and /or throat is inflamed or damaged by the stomach's highly
acidic hydrochloric acid (HCl) content when the valve between the esophagus and stomach opens at the
wrong time (i.e. other than swallowing) - an inflamed esophagus creates the sensation
of "heart-burn".
Typical triggers (include)
Overeating;
Obesity
Pregnancy
Smoking
Hiatal hernia
Ulcers
Gastritis
Consuming fried, fatty or spicy foods, chocolate, carbonated
beverages, alcohol, caffeine, others.
GERD
- stomach and esophagus
Who typically gets GERD?
GERD can occur in anyone and at any age - but increases substantially for those over the age of 40, with
> 50% of sufferers between 45 and 64;
GERD has become an epidemic problem - especially for those on the standard
Western diet. GERD affects 25-35% of U.S. population
- 10% have it every day, 44% once/month.
GERD symptoms
Include:
Heartburn; Difficulty swallowing; Coughing Hoarseness; Chest pain.
Untreated GERD can lead to:
Throat lesions; Esophagitis (esophageal inflammation
/deterioration);
How to treat GERD / "Heartburn"
Dietary changes
Calcium
Calcium is an essential mineral for muscle tone.
People with GERD tend to have
a weakened lower esophageal sphincter (LES), the muscle that would usually prevent
your stomach'scontents from coming back up.
A study in 18 people with heartburn found that taking calcium carbonate caused
an increase in LES muscle tone in 50% of cases. These results suggest that taking
this supplement to improve muscle function may be another way to prevent heartburn
(7) ).
Fat
High-fat foods relax the LES muscles, making it easier for your stomach's contents
to reflux back up (Link) . Fats are mainly digested in small intestine. Since fats take longer to digest than proteins and carbs, they delay gastric emptying.
This means that the stomach empties its contents at a slower rate — an issue that'salready common among people with heartburn (Effects of fat on gastric emptying,
Effects of incorporating
fat into meal on gastric emptying ).
Delayed gastric emptying has been associated with increased esophageal exposure
to gastric acid and a higher volume of food available to move backward to the esophagus.
These factors would
make heartburn
worse.
GERD cure using MELATONIN + vitamins + amino
acids
The GI tract represents the most important extra pineal source of
MELATONIN (secreting 400 times more than the pineal gland).
Formula used contained: melatonin,
l-tryptophan, vitamin B6, folic acid, vitamin B12, methionine and betaine
Which is the best choice for gastroesophageal disorders: Melatonin or proton pump inhibitors? :
The same formula mentioned above (melatonin combined with other natural supplements)
was also utilized in a randomized single-blind clinical trial of 351 human subjects
with gastroesophageal reflux disease (GERD) and compared with omeprazole (group
B)[9]. In this case, melatonin (combined with amino acids and vitamins) is better
than omeprazole alone[9].
Kandil et al[10] confirmed that melatonin has a role in the improvement of GERD
in human subjects when used alone or in combination with omeprazole. Meanwhile,
omeprazole alone is better in the treatment of GERD than melatonin alone. They treated
36 human subjects with GERD[10].
https://www.researchgate.net/publication/7145861_Regression_of_an_esophageal_ulcer_using_a_dietary_supplement_containing_melatonin
https://www.rainbow.coop/library/gastroesophageal-reflux-disease-treatment/
This study was done to see if a combination of melatonin (6 mg.), l-tryptophan (200
mg.), vitamin B-6 (25 mg.), folic acid (10 mg.), vitamin B-12 (50 ug), methionine
(100 mg.) and betaine (100 mg.) can relieve GERD, compared to omeprazole. One dose
was given, daily. Melatonin inhibits gastric acid secretion and nitric oxide production.
Nitric acid plays a role in relaxation of the lower esophageal sphincter muscle.
Some of the other supplements are anti-inflammatory and relieve pain.
The study was a single blind randomized study. A total of 351 patients were studied.
Half of them received the supplements as listed above and half received 20 mg omeprazole.
All patients kept a diary of their symptoms. All of the patients on the compound
had complete relief of their symptoms in 40 days. Only 2/3rd of the patients on
omeprazole had relief of their symptoms in 40 days. The differences between the
two groups were statistically significant.
CONCLUSION: A combination of supplements, with tryptophan, methionine and melatonin,
was 100% effective in relieving GERD.
De
Souza Pereira, 2006
De Souza Pereira R. (2006) Regression of gastroesophageal
reflux disease symptoms using dietary supplementation with melatonin, vitamins and
amino acids: Comparison with omeprazole. J. Pineal Res. 41:195-200.
PubMed
https://www.ncbi.nlm.nih.gov/pubmed/16948779
Findings of this single case study in addition to a review of the literature
suggest that melatonin 6 mg at bedtime may be an effective treatment for GERD with
fewer and less serious adverse effects than acid-reducing medications so long as
anti-GERD medications are (1) continued during the fi rst 40 days of treatment and
(2) resumed for at least 1 dose whenever symptoms recur.
https://todayspractitioner.com/wp-content/uploads/2015/10/0708_werbach.pdf
Acid Blockers are standard treatment for GERD
The most common GERD treatment uses proton pump inhibitors (PPI).
E.g the drug omeprazole. PPI medications reduce acid production, but do have side
effects. There is concern that chronic PPI medication can be carcinogenic.
Acid-blocking medication is the #3 top-selling drug type
in
America,
and Nexium ("The Purple Pill") and Prevacid are two of the top 10 best-selling
drugs. When acid-blocking drugs first entered the market they were considered so
potent that doctors were warned not to prescribe them for longer than 6 weeks,
and then only to patients with documented ulcers. Prilosec is now available
over-the-counter. Today, the message is "Eat what you like, then just pop in
a pill".
Taking acid-blockers reduces stomach acid (HCl) - they work by neutralizing the stomach acid, so that if it does back-up into
the esophagus, it won’t harm its delicate lining. However,
this cure is worse
than the disease because it reduces your stomach acid, which is needed
to:
Digest protein and food Activate digestive enzymes
Prevent bacteria (E.g. H. Pylori) growing in your stomach and small
intestine
Help you absorb important nutrients like calcium, magnesium, and vitamin
B12.
Insufficient stomach acid (HCl) can lead to:
Poor protein digestion - normall y
when food is eaten, sufficient HCl is required to produce protease enzymes, such
as pepsin, that break the bonds linking amino acids together.
B12
deficiency leading to depression, anemia, fatigue, nerve damage, and even
dementia, especially in the elderly - For
its absorption, B12 requires a protein made in the stomach, called intrinsic
factor. Intrinsic factor, also required for RBC formation, is not secreted
in adequate levels when stomach acid is low. Ruscin JM et al, Vitamin B(12)
deficiency associated with histamine(2)-receptor antagonists and a proton-pump
inhibitor. Ann. Pharmacother. 2002
Serious
bacterial overgrowth in intestine - called Clostridia , leading to
life-threatening infections;
Stomach
ulcers, GERD and esophageal cancer due to H. Pylori bacteria - these bacteria can grow in the mucous lining of the stomach,
duodenum, esophagus and lower esophageal sphincter (LES) walls when stomach
acidity is decreased to a pH of >= 2.3. It is well established that H.
Pylori grows best at neutral pH and fails to survive at a pH below 4.0 or
above 8.2 in the absence of chemicals such as urea. Pylori
has been strongly linked to ulcers, GERD and esophageal cancer. MD/researcher
Barry Marshall, who researched with Austrian pathologist Robin Warren (Both
awarded the Nobel Prize in Medicine in 2005) demonstrated this when he drank a
Petri dish of H. pylori and developed gastritis;
Bloating, gas, abdominal pain, diarrhea, IBS - low-grade bacterial overgrowth in
intestine promotes bloating, gas, abdominal pain, and diarrhea (all commonly
listed acid-blocker drug side-effects). Irritable bowel syndrome (IBS) can
develop as a result of bacterial overgrowth or poor food digestion
Increase in osteoporosis / hip fracture - long-term acid blocking prevents
absorption of calcium and other minerals for bone health. Yang YX et al,
Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006
Many older people don't have enough HCl in their stomach
- since HCl production declines with age.
What factors are involved in GERD?
Impaired esophageal tissue resistance - "The ability of
the esophageal mucosa to withstand injury is a factor in determining whether
reflux disease will develop, and seems to be influenced by the age and
nutritional status of the individual.
- Tissue resistance in the esophagus consists of the cell
membranes and intercellular junctional complexes, which protect against
acid injury by limiting the rate of hydrogen ions (present in
stomach acid) diffusing into the epithelium.
- The esophagus also produces bicarbonate to buffer
the acid, and mucus, which forms a protective barrier on the epithelial surface.
The resistance of the esophageal mucosa to acid damage is much less than that of
the stomach lining.
When esophageal damage occurs, there is too much acid
and pepsin present for a given level of mucosal protection. The pepsin in the
refluxed stomach acid can damage the esophagus by digesting epithelial protein."
www.gerd.com
GERD involves muscle valves at the top and bottom of esophagus and
stomach, also other muscles - a person can stand upside down after eating a
large meal, and yet no food backs up into the mouth or the esophagus because of
muscle rings in the esophagus that push food towards the stomach and the
strategic placement and mechanism of sphincter muscle valves. These
sphincters must be working correctly to allow digestive juices to flow correctly
out of the bottom of the stomach, and not out of the top.
GERD
requires relaxation of both the LES and the diaphragmatic sphincter
The associated sphincters / muscles
Esophageal Muscles - ring muscles have peristaltic action to propel food
down the esophagus;
Upper esophageal Sphincter - closes when you breathe so that air travels
down your "air pipe" and not down your "food pipe";
Diaphragmatic sphincter - Sheet muscle which separates stomach from upper
chest, contains a small opening called the esophageal hiatus, through which the
esophagus passes;
Stomach Muscles - churn food to aid digestion and move the resulting chyme
through to the small intestine.
Pyloric Sphincter - located at the pylorus, the outlet at the bottom of
the stomach. This sphincter is stimulated to open and let food out of the
stomach into the small intestine by the parasympathetic nervous system ( , the pyloric valve
does not receive the signal to open and release the stomach's acidic contents
into the intestines, until sufficient neutralizing bicarbonate has been released
from the pancreas into the duodenum. Batmangheilidj 1995.
Adequate pancreatic bicarbonate production requires sufficient minerals and water:
Stomach acid and bicarbonate buffering system
Lower Esophageal Sphincter (LES) (also called cardiac
sphincter, gastroesophageal sphincter or lower esophageal valve)- is a valve that operates like
a door, letting food into the stomach but not back up into the esophagus.
-
Ring-shaped muscle - in the lower 3-4 inches of the
esophagus below the diaphragm;
-
At rest it is contracted - to prevent the contents of the
stomach from flowing backward;
-
Triggered to relax when there is food in the esophagus -
so that food can pass through to the stomach. After food passes into the
stomach, the sphincter contracts again, closing off the esophagus;
-
Quickly regains its tone when the food has passed - A
healthy LES opens for only a few seconds in response to swallowing to allow the
passage of food.
The above sphincters and other muscles can malfunction,
due to infection, stress and nutrient deficiencies
If these muscles are not
working properly it could be due to:
- Muscle spasms - which in the case of the LES would allow acid to escape
into the esophagus. In particular, an unbalanced intake ratio of
calcium to magnesium (typically a magnesium deficiency, since calcium is
well supplied in Western diet) can cause tight, spastic muscles
- Muscle weakness - is another possibility, but there is really no good
reason for these muscles to suddenly weaken ave serious side effects limiting
their use:
- Food triggers - Alcohol, caffeine, fats can relax (i.e. open) sphincters;
- Bacterial infection - such as H.
Pylori can damage them;
- Neurotransmitter involvement - autonomic nervous system uses certain
neurotransmitter chemicals to contract muscles or inhibit contraction
Cause
What's Wrong
How Backflow Results
Malfunctioning / Weak LES
MOST GERD HAS THIS PROBLEM
LES is too Relaxed - makes it unable to maintain closure of the gate between stomach and
esophagus.
Impaired /Spastic function does not allow
esophagus to clear or causes LES to open at the wrong time -
possibly due to impaired neuromuscular
mechanisms/neuro-transmitter involvement in resting tone;
Spasticity may be due to Mg deficiency /Mg-Ca imbalance.
Leakage - may occur as a
result of damage by H. pylori bacteria
A weak/malfunctioning LES combined with high
pressure from stomach is able to overcome weak LES "gate"
Hiatal hernia - top part of the stomach
sometimes slides up and bulges through the opening (hiatus) in the
diaphragm
The LES is displaced
above the diaphragm into the chest cavity, causing it to malfunction.
Impaired /spastic muscle function of
diaphragm - could result from impaired neuromuscular
mechanisms /neuro-transmitter involvement in resting tone;
Spasticity may be due to Mg deficiency /Mg-Ca imbalance.
With the LES above the diaphragm, the LES
pressure is lower resulting in increased risk for backflow. Causes
refluxed material to remain in the esophagus longer (making damage more
likely).
Abnormal emptying or clearance of esophagus
"Lazy" esophagus - Esophageal peristalsis
moves swallowed food/liquids into the stomach. When esophageal muscle
contraction is weak or uncoordinated, moving the food into the stomach
is delayed.
Impaired esophageal muscle function could
result from impaired neuromuscular mechanisms /neuro-transmitter
involvement in resting tone;
Any delay in esophageal clearance or emptying
results in worsening of problems from backflow - By keeping stomach
fluids longer in the esophagus, it increases risk of backflow to throat
and larynx and of irritation and swelling
Delayed Stomach Emptying
(Gastroparesis)
Note:
Pyloric Sphincter is the valve at the bottom of the stomach
Gastric Dysmotility - due
to weak (low tone), strong or uncoordinated stomach muscles) -
movement of stomach contents (i.e. chyme) out of the stomach and into
the small intestine is delayed, increasing risk of backflow.
Insufficient stomach acid -
pH >3 triggers stomach lining G-cells to release GASTRIN hormone,
which signals the pyloric sphincter valve to open and let the chyme move
forward and parietal cells to release HCl
Impaired stomach muscles and/or pyloric
sphincter - could result from magnesium deficiency or
Mg/Ca imbalance.
Delayed stomach emptying puts back- pressure
on LES due to increased stomach volume.
Some disorders (e.g. diabetes/low blood
sugar; hypothyroidism; paralysis ) are associated with delayed
stomach emptying.
Abnormal Function of Upper Esophageal Sphincter (UES)
Possibly due to impaired neuromuscular
mechanisms/neuro-transmitter involvement in resting tone;
Spasticity may be due to Mg deficiency /Mg-Ca imbalance.
Stomach fluids in esophagus able to backflow
beyond upper "gate" or UES into throat and voice box
Certain Medications can Cause GERD
- Certain drugs tend to relax the LES valve - causing it to
open during normal stomach gas pressures. The worst (according
to GERD researcher Dr. Mark Hyman):
~ The channel blockers - used to treat high blood pressure;
~ Steroids - used for inflammatory conditions: arthritis, lupus;
E.g. Prednisone;
~ Statins - cholesterol-lowering drugs E.g. Lipitor
Also NSAIDS, drugs with anticholinergic effects, inhibit the transmission of parasympathetic nerve impulses that use
acetylcholine to reduce spasms of smooth muscle. E.g. LES, bladder muscles)
Some anti anxiety drugs, bronchodilators,
antidepressants, beta blockers and nitrates (e.g. nitroglycerine);
Some drugs delay the emptying of the stomach -
increasing the stomach's contents, making reflux more likely. E.g. opioids
(opioids also reduce transient LES relaxations (TLESRs)
Opening and closing the lower esophageal sphincter (LES)
The "LES Pressure" (LESP) - The LES provides a pressure
barrier between the esophagus and stomach. In addition to the LES muscle itself,
the LES pressure is determined by muscles at the bottom of the esophagus as well
as the muscles of the diaphragm that surround the bottom of the esophagus.
When it is closed, the
contraction of the LES maintains a higher pressure than
that of the stomach - so that food and digestive juices cannot
wash back into the esophagus. Mediated by the exicitory vagal motor pathway
(explained below), contractions are consequential to peristalsis-related
relaxation, increased abdominal pressure (to counter back pressure from stomach
fullness), and also, the distal Les contracts in phase with stomach
contractions.
The LES opens or relaxes,
lowering its pressure - as food is moved down the esophagus by esophageal
contractions..
The LES opens when you
swallow food or drinkThe LES opens when you
swallow food or drink - usually the LES actively remains closed to prevent
reflux of gastric contents into the esophagus, but opens by a relaxation
coinciding with a pharyngeal swallow. The LES pressure (keeping the LES closed)
returns to its higher resting level after the peristaltic wave has passed
through the esophagus, such that reflux of gastric juice that may have occurred
through the open valve during a swallow is cleared back into the stomach.
Factors that put back
( reducing LES pressure and
tending to force the LES to open ¢)
Lying down on a Full
Stomach
Your stomach takes an average of three hours
to empty after eating. Lying down too soon puts pressure on LES.
Tight-Fitting Clothing
Wearing tight clothing such as tight
belts/clothes or slenderizing undergarments, squeeze stomach putting
pressure on LES
Overeating / Obesity
Eating large quantities of food or
ill-combined foods or having a large stomach increases stomach gas
pressure.
Neurotransmitters / Hormones /Triggers that open/close
LES by increasing/decreasing LES Pressure
Increase ▲ LES Pressure (Close LES �)
-
Excitatory Neurotransmitters -
Acetylcholine, Substance P
-
Alpha-adrenergic stimulants -
norepinephrine, phenylephrine. Studies suggest a significant portion of basal
LES pressure is dependent upon alpha-adrenergic stimulation
-
Beta-blockers
- Muscarinic M2 and M3 receptor agonists
The hormones GASTRIN and motilin
√
The peptides bombesin, B-enkephalin, and substance P
√
Some pharmacologic agents such as antacids, cholinergics,
domperidone, metoclopramide, and prostaglandin F2 α
-
Decrease ▼LES Pressure (Open LES ¢)
√
Inhibitory Neurotransmitters -
VASOACTIVE INTESTINAL POLYPEPTIDE (VIP) and NITRIC
OXIDE (NO)
√
Alpha blockers (block
α-adrenergic receptors) - phentolamine;
√
Beta-adrenergic stimulants (stimulation of β2
receptors induces smooth muscle relaxation) - isoproterenol
√
Hormones - cholecystokinin (CCK), estrogen , glucagon , progesterone ,
somatostatin, and secretin .
√
Peptides - Calcitonin gene-related peptide (CGRP),
gastric inhibitory peptide (GIP), neuropeptide Y, and vasoactive intestinal
polypeptide (VIP)
√
Certain drugs - Anticholinergics, barbiturates, calcium
channel blockers, diazepam, dopamine, meperidine, prostaglandin E1 and E2,
adenosine, and xanthine derivatives (e.g. theobromine, theophylline, caffeine;
all adenosine antagonists; found mainly in chocolate).
√
Mechanical Triggers that initiate innervated inhibition
of the LES - include pharyngeal swallowing and esophageal distention due to food
bolus presence. Note that the esophageal body is not strong enough to force open
the LES if relaxation has not first been mediated by parasympathetic activity
via the vagus nerve;
√
Certain Foods/Drinks - Peppermint, chocolate, beverages
with high caffeine (xanthine derivative) content (tea, coffee, cola), ethanol,
preserved meats such as cured bacon, hot dogs (contain nitrates, which are
NO donors), and fatty meals
√
Nicotine - smoking;
√
Reflux is more common when a person is awake and in the
upright position than during sleep in the supine position - When reflux of
gastric juice occurs, normal subjects rapidly clear the acid gastric juice from
the esophagus regardless of their position.
Detailed (technical) information on LESP
Consequences of Compromised Bicarbonate Buffer and Low
Stomach HCl
GERD Connection to Compromised Bicarbonate Buffering
System - If the bicarbonate buffering system fails, then
there will also be less Hydrochloric Acid produced in the stomach.
Gastroparesis
Insufficient Magnesium and/or an Imbalance of
Magnesium compared to Calcium
In addition to maintaining body's pH balance,
magnesium also:
Ÿ
Helps keep potassium in cells to establish cell membrane potential (the cell's "battery")
Ÿ
Required for healthy functioning of nerves and muscles (including the heart)
Ÿ
Needed to activate more than 300 enzymes involved in functions in every cell
e.g. to metabolize blood sugars, proteins and carbohydrates.
Ÿ
Vital for proper bone growth and is indirectly related to adequate calcium
absorption
* Buffers are chemicals that
prevent pH from changing easily by
substituting changes in the relative
concentrations of the weak acid and its conjugate base
(formed when the weak acid gives up its proton).
Wide fluctuations in pH (H+
concentration) are prevented by the presence of several weak acid pH
buffers. These weak acids exist in equilibrium with the corresponding
base at physiologic pH. Buffers respond to changes in H+
concentration by shifting the relative concentrations of the buffer and
the corresponding base to dampen the change in pH.
Extra notes If you don’t have enough HCl and enzymes to digest
your food thoroughly, you could be subject to the problems of "gastric dumping
syndrome" (or "rapid gastric emptying syndrome" - though it may not be
rapid!), where "food is emptied too quickly from the stomach, filling the small
intestine with undigested food that is not adequately prepared to permit
efficient absorption of nutrients in the small intestine.
References
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PubMed
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"Ultraprevention: The 6-Week Plan That Will Make You
Healthy for Life", by Dr. Mark Hyman
http://books.google.com/books?id=- XjZtYyBYTQC&pg=PA75&lpg=PA75&dq=%22pyloric+sphincter%22+magnesium+deficiency&source=web&ots=U-GbgyXQaT&sig=H391hXbOUj4ExJIGeE8cgGtcXOI#PPA74,M1
http://home.hvc.rr.com/bobcotton/gerdsalt.htm#Footnote%201
