Updated: Jun 27, 2020
Heartburn is a condition in which acid from the stomach gets past the lower esophageal sphincter and into the esophagus (throat). It can cause a burning or acid sensation in the upper chest, throat and even the mouth. Some patients can actually taste the acid when it reaches the mouth, having a very distinct metallic taste. Some patients only experience the sensation of the lump in the throat or just a cough after eating meals. I've even seen cases of new onset asthma actually due to acid getting into the trachea and bronchi of the lungs and triggering constriction of the airways.
The general medical consensus is that heartburn is simply "too much acid". If you've studied digestive physiology, you would know that if this were the case, symptoms would be worse when acid levels are at their highest. This would be during and immediately following a meal. Instead, most people experience heartburn a few hours after eating, when acid levels decrease as the food moves out of the stomach and into the small intestine. The lower esophageal sphincter, located at the lower esophagus, just above the stomach, is triggered to close and tighten when exposed to increased acid levels in the stomach. So if there's so much acid, how's it getting into the esophagus?
The answer is actually a deficiency of acid in the stomach. With lower levels of acid, the lower esophageal sphincter relaxes, and as the stomach is churning food to mix with the acid and push it into the small intestine, some of that food mixed with acid leaks into the esophagus. This happens when acid levels are lower, generally a few hours after eating. It's also more common as we get older because stomach acid amounts tend to decrease with age. Also, the more fat in the meal, the slower the digestion and the more time for that food and acid to be churning in the stomach and escaping through that relaxed lower esophageal sphincter.
Over time, this constant exposure of stomach acid in the esophagus causes the cells of the esophagus to change. This is the body's attempt to adapt to the constant irritation, but what results is known as Barrett's Esophagus, a pre-cancerous condition. If the irritation continues, esophageal cancer is a real risk.
Heartburn or GERD (gastro-esophageal reflux disorder) is one of the easiest symptoms to resolve. Along with low stomach acid, there are a few other common causes and contributors that need to be addressed:
This is when there is a structural disruption of the lower esophageal sphincter. With a hiatal hernia, part of the upper stomach has squeezed above the diaphragm (it should all be below the diaphragm), and this allows more food and acid to escape into the esophagus. This is generally treatable with diet, exercises and manual adjusting of the stomach.
Increased abdominal pressure
This is common with obesity or pregnancy. Excessive abdominal fat or a developing baby is taking up additional room and putting upward pressure on the stomach and compromising the function of that lower esophageal sphincter. Weight loss for those who are overweight and/or pregnant can help significantly, as well as dietary modifications and chiropractic care.
The nicotine in smoking causes the lower esophageal sphincter to relax when it needs to be tight and closed. Needless to say, there are a multitude of reasons to seek help in quitting nicotine use in any form.
These cases tend to be more difficult to treat, as it's not stomach acid that's causing the heartburn, but instead is bile from the liver and gallbladder that is moving backwards into the upper digestive tract. Patients with bile reflux tend to not see improvement on a number of different antacids because stomach acid isn't the problem here, poor bile flow and liver congestion is. Once this is identified, there are a number of ways to support normal bile flow and liver function.
Eating a food that is poorly digested and creating inflammation in the digestive tract can decrease acid levels and can compromise healthy stomach function. Simply removing these foods from the diet can resolve the heartburn.
So what about antacids?
Medications that are used to decrease stomach acid may help temporarily by making the acid more alkaline and less irritating to the esophagus. However, this fails to fix the problem.
Simply changing the pH of the acid doesn't prevent the food and acid from still escaping into the esophagus and causing damage, you just don't feel it because it's less acidic.
Instead, I'd suggest addressing the cause and optimizing stomach function and acid production. Stomach acid is normal and necessary for nutrients to be absorbed and protein to be properly digested. People who take antacids on a regular bases tend to become deficient in calcium, magnesium, zinc, iron and even B12. PPI's (proton pump inhibitors) such as Nexium, Prilosec, Prevacid and similar decrease normal stomach acid production by 99%, making nutrient absorption and protein breakdown near impossible by the stomach and taxing the rest of the digestive system which attempts to pick up the slack. Osteoporosis is a real risk with long term acid suppression therapy due to the decreased calcium absorption.
Stomach acid also plays a role in preventing infections of the digestive tract. The acid helps kill bacteria which may be hitch-hiking a ride on your food from being able to colonize and create dysbiosis, or an excessive growth of pathogenic bacteria in the lower digestive tract. Clostridium difficile is one in particular. Good bacteria such as lactobacillus species prefer to live in an acidic environment, so when the conditions become more alkaline, they won't grow. We need to create the right environment for the good bacteria to grow and flourish, and acid suppressing medications don't help.
Medications such as the PPIs listed above are not recommended past 6 weeks of use. Controlled studies have not extended past 6-12 months. Yet daily, I see patients who have been given prescriptions for these medications long term. No study has conclusively determined the long term safety of these medications, and we know long term effects are seen on the stomach, such as stomach polyps, or growths, which begin to develop and even increases the risk of stomach cancer over time. Why are these medications routinely used for long term management? Why aren't we addressing the cause and eliminating the need for these medications long term? Probably because the cause of heartburn is still thought to be "too much acid".
Interested in being evaluated to determine the cause(s) of your chronic heartburn? Schedule today and start getting it resolved, not managed with an acid suppressing medication that will increase your risk of stomach cancer, osteoporosis, GI infection and nutrient deficiencies.
Long-term Use of Proton-Pump Inhibitor Therapy, David C. Metz, MD, U.S. Pharmacist
Long-term Consequences of Chronic Proton Pump Inhibitor Use, LeAnn W. O'Neill , US Pharmacist
Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study, Ka Shing Cheung
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