What Really Causes GERD (Gastroesophageal Reflux Disease) and How Should It Be Treated?

by Ram

Damage by Melina Meza

GERD (gastroesophageal reflux disease) is a digestive disorder characterized by recurrent reflux of acid from the stomach into the esophagus triggering heartburn or acid indigestion. The esophagus is a muscular, tube-like structure that connects the throat to the stomach, which is lined by a moist, pink, gel-like tissue called mucosa. The food that you eat moves from your throat down to the esophagus. Two valve-like muscular structures exist in the esophagus to regulate the flow of the nutrients to the correct destination (from the esophagus to stomach to the small intestine). The upper esophageal sphincter (UES) at the top of the esophagus prevents food and other secretions from entering the windpipe by opening or closing at the appropriate time. The lower esophageal sphincter (LES) present at the esophagus-stomach junction prevents the stomach acids from traveling into the esophagus through its appropriate open-close function. 

Gastroesophageal refers to the stomach and esophagus. Reflux means return or flow back. Thus, gastroesophageal reflux is the reverse flow of stomach acids back up into the esophagus, either due to weakening of the lower esophageal sphincter muscles or due to inappropriate closure of the lower esophageal sphincter valve. Certain foods, fermented or fizz drinks, acidic fruits, cigarette smoke, and chronic stress can all cause the lower esophageal sphincter valve to relax, resulting in acid reflux into the esophagus. If this situation happens as a one-time event or acutely it is termed as a heartburn/acid reflux. If it is long lasting and a more serious form or a chronic issue, it is termed as gastroesophageal reflux disease (GERD).  

The most common symptom of gastroesophageal reflux disease (GERD) is heartburn. If the condition persists, additional symptoms may also appear, including a sour taste in mouth, chest pain, difficulty swallowing, dry cough, sore throat, and spewing of sour solids or liquids. Most people can manage the discomfort of GERD with lifestyle changes and over-the-counter medications. Over-the-counter treatments that may help control heartburn include:

1. Antacids that neutralize stomach acid
2. Acid production blockers, also called as H-2-receptor blockers, which provide longer relief and may decrease acid production from the stomach for up to 12 hours
3. Proton pump inhibitors, which are even stronger than H-2-receptor blockers of acid production

However, prolonged use of any of the above-mentioned medications can produce side effects, such as diarrhea, constipation, fatigue, confusion, or bone loss. If the heartburn and other symptoms don�t improve with lifestyle changes and medications, surgery may be the ultimate option. And while the symptoms of the heartburn may temporarily cease through the use of the above-mentioned medications, blocking the acid production is not a good remedy. There is a reason for the presence of acid in the stomach: it is necessary for proper digestion of food. The enzymes that digest the food completely work efficiently in the acidic environment. It is this combination of the acid and the enzymes in the stomach that facilitate efficient digestion of food to a form that can be easily delivered to the small intestine for further digestion and absorption. While the strength of the stomach acid is strong enough to burn a hole through a piece of wood, the stomach itself is well protected from its own acids. However, unlike the stomach, the esophagus does not possess any protective inner lining, resulting in its damage by the acids that shows up as a burning heartburn. This has been the premise so far. 

But now a new research study is changing this long-held paradigm (see Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes). According to this new study, the stomach acid backing up into the esophagus does not cause chemical burns and damage to the lining of the esophagus as thought earlier. Instead, the researchers from UT Southwestern-Dallas VA hospital suggest that the damage in patients with GERD actually occurs owing to an inflammatory response prompted by the secretion of inflammatory proteins called cytokines. The research work done in mice demonstrates that it takes several weeks for the stomach acid to initiate any damage in the esophagus. So it is unlikely that acids are the cause of the chemical burn since burns develop immediately. In follow-up studies on humans, the researchers followed 12 patients who suffered from chronic GERD. The patients who were taking proton pump inhibitors to control the acid reflux were asked to stop taking the medication. The researchers thought that GERD might redevelop if the medication were to be stopped, providing an opportunity to observe the early changes of GERD. Nearly all of the patients showed damages to the esophagus after stopping the medications. More importantly, the damages that reoccurred were not consistent with acid-triggered burns. Rather, the changes revealed all the tell-tale signs of an inflammatory response, suggesting that the stomach acid in the esophagus actually triggered a pro-inflammatory response by stimulating the production of small molecules called cytokines that trigger�s the body�s own defense system to go awry (see Chronic Inflammation and Yoga: Combating the Fiery Killer).

So what�s in this for the doctors and pharmacists? Since the study challenges a long-held belief about the role of the acid in damaging the esophagus, it is important for medical personnel to have the correct understanding of the mechanisms underlying GERD in order to facilitate novel GERD in order to facilitate novel GERD treatments. 

And what does it mean for people who have the condition and are desperate to jump off the antacid/PPI bandwagon? Good eating habits and good lifestyle practices that include a regular yoga practice go a long way in strengthening the gut. A balanced yoga practice includes asanas, resting poses, pranayama and meditation, all of which support the best possible digestion via our conscious mind and the autonomic nervous system (see The Digestion System and Yoga). As I mentioned in the beginning, chronic stress�which can over-activate the sympathetic nervous system (your Fight or Flight response)�is the single most common trigger of GERD (Our Hyper-Competitive, Stressful World), so consider meditation and restorative yoga practices when you know you are under lots of stress (see How to Practice If You Have Digestive Problems). All of the above practices together with healthy food choices and timely meals will promote a healthy digestion that is required to maintain a long health-span (Why You Should Care About Your Digestive System). So one alternative to consider working your way to healthy aging is by closely listening to your gut!

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How to Practice If You Have Digestive Problems

by Baxter and Nina

Doctor and Doll by Norman Rockwell*

In general, a balanced practice that includes a well-rounded selection of active poses plus stress management will help keep your digestive system healthy. However, if you are currently having digestive problems or if you�re one of those people who have a sensitive digestive system, you can use the techniques we�re recommending here to improve your digestion.

Before practicing, consider your current condition. If you are presently in good health, we recommend that you practice a well-balanced yoga sequence that includes active poses, (both dynamic and static) and restorative poses or gentle supported inverted poses, along with meditation, breath work, or conscious relaxation. The active poses will provide exercise that is beneficial for your digestive system, supporting good circulation to your digestive organs, strengthening the muscular supports around your digestive organs, and stimulating good elimination. The restorative poses, meditation, breath work, and/or conscious relaxation will allow you to spend more time in the Rest and Digest state, which allows your digestive system to function optimally.

If you�re currently having digestive problems, we recommend that you focus mainly on gentle asana, restorative poses, and conscious relaxation, which will allow you to spend more time in the Rest and Digest state while also reducing overall stress levels that could be contributing to your problems. As you start to return to normal functioning, gradually add in more physical challenges in a step-wise fashion. For standing poses, start with dynamic poses, as they are less demanding than static standing poses, and eventually add in static poses when you�re ready. 

Cautions: Using asana for exercise is not recommended for severe cases of diarrhea or constipation, or if you�re having an acute bout of pain related to your digestive disorder. In these cases, we recommended turning to restorative yoga and stress management. For severe diarrhea in particular, Legs Up the Wall pose with a small support under the hips provides a slight inversion that could slow down diarrhea while shifting you to the Rest and Digest state. For conditions where pressure on your belly is painful, avoid restorative poses, such as supported Child�s pose, that cause abdominal discomfort.

How Often to Practice. If you�re currently having digestive problems, practice five to six days a week, alternating days of gentle asana practice with quiet days of restorative yoga and conscious relaxation. If you�re suffering from chronic stress, however, we recommend including a short stress management session six to seven days a week (see Stress Management below).

What to Practice. We recommend that your sequences include a mix of active asanas and restorative poses, as well conscious relaxation, breath work, or meditation. Depending on the type of digestive problems you have, what you practice for the asana section of your sequence will need to vary quite a bit, as you learn what works for you. However, in general, it�s wise to start with gentler asanas, including gentle reclined and seated poses, chair variations of standing poses, gentle supported inversions, and restorative poses. Gradually add in more challenging poses, including both static and dynamic poses, as you monitor the response of your digestive system to them. 

Static Poses. Focus on static poses that strengthen and stretch your abdominal area to help tone your abdominal muscles that house and support the majority of the organs of digestion, and that can assist in moving material through your system. These include:

• Back-bending poses, such as Warrior 1, Locust, Cobra, Upward-Facing Dog pose and Bridge pose, which all stretch the front of your abdomen and strengthen the back of your torso.
•  Side-bending poses such as Crescent Moon pose, Easy Sitting Side Bend, Triangle pose, and Extended Side Angle pose, which stretch and strengthen the sides of your abdomen.
• Seated and standing forward bends, which apply pressure to your abdominal area, strengthening the front of your abdomen while stretching your back, and may assist in moving material through the system. 
• Seated or reclined twists, which squeeze your abdominal area, stretching your back and strengthening the front of your abdomen, and may assist in moving material through the system.

Dynamic Poses and Flow Sequences. Focus on dynamic poses that fold, stretch and twist your abdominal area to improve blood and lymph circulation, and create a squeeze and release affect on your organs, which may support improved functioning and stimulate good elimination. These include:

• Sun Salutations
• Cat/Cow
• Mountain pose to Arms Overhead pose to Standing Forward bend and back
• Seated twists and side bends done dynamically

Restorative Poses and Conscious Relaxation. We highly recommend practicing restorative poses where your chest is lifted and your belly is very relaxed, such as Reclined Cobbler�s pose, because these may bring you quick relief. In addition, if you have sluggish digestion or elimination, we recommend practicing Child�s pose with a bolster to see if that helps. If you have a condition that is worsened by anxiety or stress, we recommend practicing conscious relaxation in Savasana with support for your chest, and bring your mental focus to your abdomen, simply noticing any sensations that arise. 

Stress Management. One of the most effective ways to influence your digestive system over time is to practice stress management techniques�including meditation, pranayama, restorative yoga, and conscious relaxation�as often as you can manage, every day, if possible. Reducing stress levels improves the functioning of your digestive system. It also helps reduce stress eating. While we can�t say that any of the stress management techniques are better than others, you may find that one or two work best for you. So, if possible, practice all of them periodically to be familiar with all of them. You can practice any of these stress management techniques as a part of your regular asana practice or on their own, at a different time of day. See Stress Management Techniques for When You're Stressed.

Meditation. While meditation is an effective way to spend time in the Rest and Digest state and therefore support your digestive system, a regular meditation practice can also improve your digestion by allowing you through mindfulness to learn about eating habits that may be contributing to your problems and by fostering will power to change them. If you are concerned about using your practice to learn about the effects of various foods on your digestive system, use meditation practices that focus on your physical sensations, such as your breath or even the sensations that are arising in your abdominal area. For improving willpower with meditation as a way of changing unhealthy eating habits, any meditation technique will do. See Yoga Meditation Techniques. 

Sleep. If you are having ongoing sleep problems, focus your practice on improving the quality of your sleep, as it will greatly benefit your digestive system by providing a prolonged rest for your entire system, during which you spend time in the Rest and Digest state. See 5 Tips for Better Sleep for recommendations.

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Why You Should Care About Your Digestive System

by Baxter and Nina

Chocolate Kouign Amann by Rosie Gibson

At a very primary level, your digestive system is essential for maintaining your health. After those first gasps of air and the initial cry of a newborn, the first action of a new life is to feed! And a digestive system in decline can be one of the first signs of serious illness or advanced age. The digestive system provides the following four basic functions:

1. Ingestion. Using your mouth to take in foods and fluids, chewing the food, and then swallowing both chewed foods and fluids.
2. Digestion. Breaking down what you eat and drink into smaller and smaller particles, which can then be absorbed into our blood. Anything that can�t be absorbed is passed on for elimination.
3. Absorption. The process of passing the small particles of digested food from the digestive tract into your blood stream, where they can be delivered for fuel to your 70 trillion cells by the circulatory system.
4. Elimination. Removing leftovers of the digestive process that you cannot use from your body. 

These four functions are the how your digestive system provides you with the fuel your body needs to function every day as well as to create the building blocks needed for to growth and repair. And this is also how your digestive system removes waste from your body, a process that is as necessary for your health as ingesting and digesting your food. 

In general, staying physically active, eating a healthy diet and taking in adequate liquids, resting after meals if you can and sleeping well, and good oral care helps you maintain the health of your digestive system. However, one of the most important things you can do to keep your digestive system functioning optimally is to keep your stress levels in check, as stress can have a huge impact on your digestion. (Nina can testify to this, because when she's very stressed out, she literally becomes so nauseated that she can't even eat at all!)

Now let�s take a look at the actual components of your digestive system and the related systems, and the effect that stress can have on them.

Mouth, Tongue, Teeth and Pharynx. Digestion begins as you take food and drink into your mouth and start to break down the food into smaller bits by chewing it and mixing it with your saliva, which contains digestive enzymes. In some people, acute stress can temporarily turn off the production of saliva, negatively affecting your initial breakdown of food.

Esophagus. This tube that runs from the back of your throat to your stomach sack moves your partially mixed food and water to your stomach. In some people, stress can interfere with the smooth muscle rhythm that moves food to the stomach, creating difficulty in swallowing. 

Stomach. Continues digestion by releasing stomach acids and enzymes, and by churning the stomach contents to further break down solids and liquids. In some people, stress can negatively affect digestion by contributing to minor digestive problems, such as heartburn and nausea, as well as more serious problems, such as acid reflux and ulcers. 

Small Intestines. After the stomach finishes its work, the small intestines (a 15-17 feet long tube) use more digestive enzymes to break down the food into even smaller particles of sugars, fats and proteins, which near the end of the tube are then absorbed into your bloodstream. In some people, stress can interfere with smooth movement of food downstream and/or with healthy absorption of food into the circulatory system. 

Large Intestines. After the food particles are absorbed, the large intestines (the final 4-5 feet of tubing that follows after the small intestines), allow most of the remaining water content for our food and fluid intake as well as vitamins and salts to be absorbed into our bloodstream. The waste that remains is collected here and then expelled through your rectum and anus in the form of a bowel movement. Your large intestines are also where much of your gut microbiome lives (see below). In some people, stress can affect the performance of the large intestines, resulting in constipation or diarrhea. 

Liver. Although it has many other functions, the liver aids digestion by producing bile salts, which assist in the breakdown of fatty foods. In some people, stress can produce inflammation in the liver that could contribute to the development of serious liver diseases such as cirrhosis, which will ultimately affect digestion (and cause other serious problems).

Gallbladder. Stores the bile salts made by the liver and releases some into the small intestines when fatty foods are detected. In some people, stress can inhibit the normal release of bile from the gallbladder into the small intestines, which will negatively impact your ability to digest fats appropriately. 

Pancreas. Although it has other functions, the pancreas aids digestion through the production and release of digestive enzymes into the small intestines. In some people, chronic stress makes the pancreas more susceptible to diseases, such as pancreatitis, which will negatively affect its ability to produce digestive enzymes.

Gut Microbiome. The community of microorganisms living in our large intestines and elsewhere in our digestive system make up our gut microbiome. Our gut microbiome has a variety of functions, including the metabolism of certain nutrients in our food, the regulation of our immune system, and modulating various behaviors such as hunger, satiety, and sleep. Maintaining a large variety of the organisms in our gut microbiome is important for the health of our digestive and immune systems as well as for the other systems that interact or communicate with our digestive system, such as the central nervous system. In some people, stress can negatively affect the diversity of the gut microbiome, which has a negative impact on our digestion and overall health.

Enteric Nervous System. A semi-independent web of nerves, the enteric nervous system, sometimes called the gut brain, helps coordinate some of the digestive processes that takes place from the stomach to the beginning of the large intestines, and also signals the brain information that results in feelings of hunger and satiety, whether or not you�re experiencing stress, and if you�ve ingested a disease-causing microbe. 

In some people, stress can interfere with normal signaling of the enteric nervous system contributing to gut symptoms such as cramping and bloating, or causing confused signaling of hunger after stress events that leads to stress eating.

Central Nervous System. To help coordinate your digestive processes your brain is in constant two-way communication with your digestive system though your autonomic nervous system and your hormones. Because of this two-way communication, the health of the central nervous influences the health of the digestive system, and the health of the digestive system influences the central nervous system.

And your state of mind has a profound effect on your digestion. When you are in a state of acute stress, your brain shuts down your digestive system temporarily until the emergency has passed. And when stress is chronic and ongoing, your digestion is compromised because your digestive system isn�t functioning optimally. 

On the other hand, when you�re relaxed and in the Rest and Digest state, your brain turns on the digestive functions that were offline while you were stressed, and is able to work in greater harmony with other systems that support good digestion.

Circulatory System. Delivers absorbed food particles to all the cells, structures and organs of your body, including your digestive system organs themselves by the circulatory system. Water not needed for body functions eventually gets delivered to your kidneys for elimination. In some people, stress can disrupt the normal blood flow to the digestive system, especially to the small intestine, which can compromise the absorption of food into your body. 

Immune System. Along the route of the digestive system are immune functions that are an integral part of the immune system. Examples include:

• salivary enzymes in the mouth, which can kill some organisms that come in with our food
• acidic fluid of the stomach sack, which can kill some invading organisms
• Peyer�s patches, special groups of immune cells that line the inside of small intestines, which can detect and start to fight invaders that make it past the mouth and stomach
• gut microbiome, which may help our immune system adapt more quickly to new infections in the gut

So maintaining the health of your digestive system will aid the functioning of your immune system, just as maintaining the health of your immune system will aid the functioning of your digestive system by keeping your digestive system healthy (see Techniques for Supporting Your Immune System with Yoga).

Because of the importance of your digestive system to the health of your entire body, maintaining healthy digestion is an integral aspect of healthy aging. In general, a well-rounded yoga practice will allow you do this by providing the exercise and stress management�especially stress management!�that you need to keep your digestive system functioning optimally. But if you are experiencing digestive problems, you can target your yoga practice to improve your digestion (see How Yoga Helps Your Digestive System).

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