GERD - NOT A PROBLEM OF TOO MUCH STOMACH ACID, BUT RATHER NOT ENOUGH ACID
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)
GERD - stomach and esophagus
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.
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)).
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.
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.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 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
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:
Insufficient stomach acid (HCl) can lead to:
Poor protein digestion - normally 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.
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
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 (causes relaxation).To protect the intestinal lining, 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. Instead, the pyloric valve constricts more tightly and the LES relaxes, setting the stage for GERD. 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.
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 throughout the body;vide only short-term relief;
- 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
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)
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.
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.
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Factors that put back pressure on LES ( reducing LES pressure and tending to force the LES to open ¢) |
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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. |
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Tight-Fitting Clothing |
Wearing tight clothing such as tight belts/clothes or slenderizing undergarments, squeeze stomach putting pressure on LES |
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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 F2α
- 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. Low stomach HCl means digestion is prolonged, which causes what is called "delayed emptying" of food from stomach into intestines. An overly full stomach is more liable to cause reflux.
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
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* 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. |
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.
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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
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