Gastroesophageal Reflux Disease (GERD) 

What Is Gastroesophageal Reflux Disease (GERD)?

[dropcap]G[/dropcap]ERD is an upper digestive disorder that is characterized by a decrease in lower esophageal sphincter pressure (LES,) which allows the abnormal reflux or backflow of stomach contents into the esophagus. It is also called erosive esophagitis or reflux esophagitis and is the most common disorder of the esophagus.

The esophagus is a muscular tube that transports swallowed substances to the stomach. It begins at the cricoid cartilage (Adam’s apple) as a continuation of the pharynx and ends at the lower esophageal sphincter (LES).

The lower esophageal sphincter is located at the junction of the esophagus and the stomach. It functions like a circular band to tighten after food is ingested in order to prevent its going back up the esophagus.

Q: How does reflux damage the esophagus?

A: Damage to the lining of the esophagus is induced by the caustic, chemical action of acid and pepsin in gastric juice and, in severe cases, also bile salts, that back upwards from the stomach through an impaired LES. Gastric acid combined with pepsin or bile salts seems to be more harmful to the esophageal epithelial layers than gastric acid alone.¹

Pepsin is normally produced by the stomach to dissolve protein in swallowed food. Unfortunately, when the esophagus is inflamed, pepsin will act on it to break down the protein in its sore wall. These sores are called erosions.

Importantly, refluxate to the esophagus in patients with acid suppression therapy is different from those in patients without. Higher levels of secondary bile acids are detected in patients with acid suppression therapy. Even if acid suppression is successful, weakly acidic reflux with bile acids can damage the esophagus.¹

Damage starts at the luminal surface (inside where food passes through) of the squamous epithelium (tough surface cells) and progresses through the underlying layers into the submucosa.

One of the primary functions of the esophageal epithelium is to protect the underlying tissue from mechanical and chemical damage by acting as a barrier. The epithelial layers of the distal esophagus need to withstand reflux from the stomach and its contents. When the epithelium fails to protect the underlying tissue from this damage, it leads to erosions, esophagitis, and may lead to Barrett’s esophagus.¹

Barrett’s esophagus and esophageal small cell cancer are severe complications of GERD that can be fatal.

GERD can result from too much, or more commonly, too little stomach acid.

What Is Gastroesophageal Reflux Disease (GERD) In Celiac Disease and/or Gluten Sensitivity?

• Relationship between GERD and celiac disease. Gastroesophageal reflux disease (GERD) is an atypical symptom of celiac disease.

• Relationship between GERD and gluten. Research shows that a gluten free diet significantly decreased the relapse rate of GERD symptoms suggesting that celiac disease may represent a risk factor for the development of reflux esophagitis.²

• Relationship between GERD and gluten free diet. A study investigating the prevalence of GERD symptoms at diagnosis and the impact of the gluten-free diet found that GERD symptoms are common in classically symptomatic untreated celiac disease patients and that the gluten free diet is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population. At baseline, 30.1% of celiac disease patients had moderate to severe GERD (score more than 3) compared with 5.7% of controls. Moderate to severe symptoms were significantly associated with the classical clinical presentation of celiac disease (35.0%) compared with atypical/silent cases (15.2%). A rapid improvement was evidenced at 3 months after initial treatment with a gluten free diet with reflux scores comparable to healthy controls from this time point onward.³

How Prevalent is GERD In Celiac Disease and/or Gluten Sensitivity?

• Celiac patients have a high prevalence of reflux esophagitis. Retrospective study shows 19% in patients undergoing endoscopy for biopsy.⁴
• At diagnosis, celiac patients had a significantly higher reflux symptom mean score than healthy controls: 30.1% of celiac disease patients had moderate to severe GERD (score >3) compared with 5.7% of controls. Moderate to severe symptoms were significantly associated with the classical clinical presentation of celiac disease (35.0%) compared with atypical/silent cases (15.2%).³
• Of 212 patients undergoing upper endoscopy for dypepsia, 3.3% of patients showed histopathological changes typical of celiac disease on duodenal biopsy. 8.5% of patients had gastric reflux.⁵

What Are The Symptoms Of GERD?

GERD is marked by these symptoms:

• Chest pain that may resemble angina in half of patients.
• Dysphagia (difficulty swallowing)
• Fullness under breastbone.
• Heartburn (burning sensation behind the breastbone).
• Regurgitation of bitter tasting fluid.

However, reflux can occur without symptoms.

How Does GERD Develop In Celiac Disease and/or Gluten Sensitivity?

• GERD results from gluten exposure and increased abdominal pressure in active celiac disease against the lower esophageal sphincter.

Does GERD Respond To Gluten Free Diet?

Yes. Gluten free diet significantly decreases the relapse rate of celiac disease-related GERD symptoms.⁴

The gluten free diet is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population. A rapid improvement was evidenced at 3 months after initial treatment with a gluten free diet with reflux scores comparable to healthy controls from this time point onward.⁶

6 Steps To Improve GERD In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both GERD and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Bad Fats. Includes deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Hot Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Relax the lower esophageal sphincter and disrupt intestinal permeability causing leaky gut.⁸[/box]

 

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 for examples such as calendula.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap]Manage Your Medications  Safely: 

Certain prescription drugs that are commonly prescribed for GERD deplete nutrients. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS – Pepcid®, Tagamet®, Zantac®, Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®). Prevacid®, Prilosec®.  Alka Seltzer®, Baking Soda

DEPLETE THESE NURIENTS – Calcium, Chromium, Folic Acid, Iron, Vitamin A, Vitamin B12, Vitamin D,      Zinc, Magnesium, Copper, Potassium. Vitamin B12.  Folic Acid, Magnesium, Proteins, Potassium

 

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• L-glutamine 250 to 500 mg  just after eating has been shown to heal the esophagus.⁹This is a safe dose, but always check with your doctor to avoid interactions with medications or if you are on a low protein diet since this is an amino acid. L-glutamine is a natural fuel for the cells that line the intestines.
• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies:

Carminatives are plant sources that tone muscle and improve peristalsis, and thus aid in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort. However, some carminitives  relax the lower esophageal sphincter thus aggravating GERD. DO NOT use these carminitives: fennel, lemon balm, peppermint and spearmint. The same goes for cigarette smoke, alcohol, high fat foods, mints, chocolate, onions, and caffiene.

[box type=”shadow” ]Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets stimulate and improve digestion and are easily digested.
• Cabbage stimulates and improves digestion and is also a liver decongestant. Proven to help GERD.
• Lettuce stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Dandelion is a digestive and liver tonic, bile stimulant, and mild laxative.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Parsley relieves colic, gas and indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is a soothing remedy useful for stimulating digestion of rich, fatty foods.
• Calendula is also an astringent and anti-inflammatory that makes it an effective remedy for GERD. Use as a tea. (Steep a teaspon of flowers in a cup of hot water for 10 minutes.)

Carminative Spice Remedies:

• Cloves are antispasmodic.
• Nutmeg is also useful for abdominal bloating, indigestion and colic.
• Ginger also supresses inflammation.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About GERD In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Endoscopic and histopathological findings of the upper gastrointestinal tract in patients with functional and organic dyspepsia.” This retrospective study investigating the frequency and type of the macroscopic and histopathological changes in the upper gastrointestinal (GI) endoscopy in patients with symptoms of dyspepsia verified that regardless of the severity of lesions of the upper GI endoscopy in patients with dyspepsia, it is advisable to biopsy from both the gastric and duodenal mucosa, which allows for an individualized management of these patients. Celiac disease should be considered in the diagnosis of the causes of dyspepsia. Reflux esophagitis was found in 8.5% of patients.

Included in this study were 212 patients with dyspepsia, at the age of 18-84 years, including 60 patients to 45 years of age (group I) and 152 patients older than 45 (group II) who underwent gastroscopy. The severity of esophagitis was classified according to the Los Angeles Classification and gastritis according the updated Sydney system. Biopsy specimens were taken from the gastric and duodenum for histopathological examination.

Reflux esophagitis was found in 18 patients (8.5%), slightly more common in people over 45 years of age (group I–5%, group II–9.2%). The mild forms of esophagitis occurred most frequently. A more advanced form of inflammation and Barrett’s esophagus was found only in patients over 45 years of age. Normal gastric and duodenal mucosa was revealed in 30% of patients in group I and 9.2% in group II. The most common endoscopic disorder was gastritis, mostly erythematous-exudative and less often atrophic.

The majority of patients had normal duodenal mucosa. In 3.3% of patients (group I–8.3%, group II–1.3%), who had not previously been diagnosed celiac disease, histopathological changes typical of celiac disease has been shown. In all patients, in whom biopsy specimens were taken from normal duodenal mucosa (14% of patients), histopathological examination revealed the presence of non-specific inflammation, regardless of the coexistence of H. pylori infection.⁵

“Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet.” This study investigating the prevalence of GERD symptoms at diagnosis and the impact of the gluten-free diet found that GERD symptoms are common in classically symptomatic untreated celiac disease patients and that the gluten free diet is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population.

Subjects consisted of 133 adult celiac disease patients evaluated at diagnosis and 70 healthy controls. Fifty-three patients completed questionnaires every 3 months during the first year and more than 4 years after diagnosis. GERD symptoms were evaluated using a subdimension of the Gastrointestinal Symptoms Rating Scale for heartburn and regurgitation domains. At diagnosis, celiac patients had a significantly higher reflux symptom mean score than healthy controls. At baseline, 30.1% of celiac disease patients had moderate to severe GERD (score more than 3) compared with 5.7% of controls. Moderate to severe symptoms were significantly associated with the classical clinical presentation of celiac disease (35.0%) compared with atypical/silent cases (15.2%). A rapid improvement was evidenced at 3 months after initial treatment with a gluten free diet with reflux scores comparable to healthy controls from this time point onward.¹⁰

“Reflux esophagitis in adult coeliac disease: beneficial effect of a gluten free diet.” This study evaluating whether untreated celiac patients had an increased prevalence of reflux esophagitis and, if so, to assess whether a gluten free diet exerted any beneficial effect on GERD symptoms demonstrated celiac patients have a high prevalence of reflux esophagitis. That a gluten free diet significantly decreased the relapse rate of GERD symptoms suggests that celiac disease may represent a risk factor for the development of reflux esophagitis.¹¹

Sources:

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5. Piatek-Guziewicz A, Przybylska-Feluś M, Dynowski W, Zwolińska-Wcisło M, Lickiewicz J, Mach T. Endoscopic and histopathological findings of the upper gastrointestinal tract in patients with functional and organic dyspepsia. Przegl Lek. 2014;71(4):204-9. [↩] [↩]
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10. Saad R, Bellec V, Dugay J, Blanchi A,Nachman F, Vázquez H, González A, Andrenacci P, Compagni L, Reyes H, Sugai E, Moreno ML, Smecuol E, Hwang HJ, Sánchez IP, Mauriño E, Bai JC. Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet. Clin Gastroenterol Hepatol. 2011 Mar;9(3):214-9. doi: 10.1016/j.cgh.2010.06.017.. [↩]
11. Cuomo A, Romano M, Rocco A, Budillon G, Del Vecchio Blanco C, Nardone G. Reflux oesophagitis in adult coeliac disease: beneficial effect of a gluten free diet. Gut. Apr 2003;52(4):514-7. [↩]