Combating GERD, Ulcers and Gastritis: Are PPIs the Answer?

Adapted from episode 80 of The Perfect Stool podcast hosted by Lindsey Parsons, EdD and edited for readability.

Combating GERD: Are PPIs the Answer?

So you may have heard the term PPI being thrown around. It stands for Proton Pump Inhibitor, which is one of the most commonly prescribed and taken medications in the US, primarily for acid reflux or GERD (gastroesophageal reflux disease), with 15 million Americans a year using them. Some examples of these are Nexium, Protonix, Aciphex, Omeprazole, Prilosec and Prevacid. They have been available over the counter since the early 2000’s, and as a result, many people think they’re a viable long-term solution for acid reflux, despite having a strong warning on the package to not use them for more than 2 weeks straight.

In addition to their use for GERD, PPIs are also prescribed for ulcers, gastritis and Zollinger-Ellison syndrome (ZES). I’m doing to dig in a little more on each of those conditions, their root causes and the long-term drawbacks of PPI usage, so you can investigate other alternatives.  

What is GERD?

So the most common reason your doctor may prescribe or recommend a PPI is GERD or acid reflux, which affects between 18-28% of Americans and over 20% of people in the Western world. Gastroesophageal reflux occurs when the lower esophageal sphincter (the valve at the bottom of the esophagus) lets acid up into the esophagus. Common GERD symptoms include:

  • trouble swallowing;
  • heartburn;
  • a foul or acrid taste in your mouth;
  • regurgitating food (although what I used to get was just little bits of food in my mouth in the morning, indicating it had been coming up during the night);
  • upper abdominal chest pain;
  • sore throat; and
  • vomiting.

While after a big or particularly unhealthy meal anyone may have these types of symptoms, if they’re happening on a regular basis, you may have GERD.

What is LPR?

Then there is another type of GERD, called LPR or laryngopharyngeal reflux, which is the type I had. For me its main manifestation was a chronic cough, usually worst in the 30-60 minutes after I ate, a feeling of warmth and sometimes hunger about an hour after eating in my chest, post-nasal drip, frequent throat clearing, hoarseness, and a lump and mucous in my throat. It can also include persistent irritation of the throat, the vocal cords, respiratory problems and plugged Eustachian tubes, which connect your middle ear to the back of your nose and throat.

So this was the condition I was dealing with when my doctor first suggested PPIs to me. I subsequently took them continuously for about 10-15 years, which may have contributed to my other issues that arose after that. And I’ve since learned that meta-analyses of PPIs for LPR have shown they’re no better than a placebo.

What are the risk factors for GERD and LPR?

Anyone can develop GERD or LPR, but some are more at risk than others. You are most likely to develop GERD if you are:

  • Overweight;
  • Taking medications that cause acid reflux;
  • Pregnant;
  • Smoking regularly;
  • Drink alcohol regularly;
  • Have an autoimmune disease called scleroderma; or
  • Have a hiatal hernia (which is when the upper part of the stomach bulges into the diaphragm).

Let unaddressed, GERD is not life threatening on its own, but long-term and untreated GERD could lead to serious health issues, like esophageal cancer, not to mention the discomfort you deal with. So while the kinds of recommendations my doctor made to me about not going to bed until 2 hours after a meal or putting the head of your bed up on blocks to sleep at an angle or even sleeping in a recliner, may have been well-intentioned, they never got at the root cause of my reflux.

Is GERD always caused by high stomach acid?

When doctors recommend PPIs for GERD, their assumption is that you have too much stomach acid. But one of my former podcast guests, professor of naturopathic gastroenterology and author of a textbook on functional gastroenterology, Dr. Steven Sandberg-Lewis, performs the gold standard test for stomach acid with his patients called the Heidelberg test, and over the years has found that 75% of them actually have low stomach acid, or hypochlorhydria, and only 25% of them have excess stomach acid. In addition, some have hidden hypochlorhydria, which means that they have some normal stomach acid on the first challenge, but it runs out after a while, meaning there’s not enough of it to digest a meal.

While most people won’t have access to this test to determine officially whether they have too much or too little stomach acid, there are a couple easy ways to determine what’s likely. One way is by taking one capsule of Betaine HCl halfway through a meal with 6 oz. of animal protein. If you feel burning or warmth in your chest, you probably have adequate stomach acid. But you should check at a few different meals to be sure. You can always neutralize the acid with TUMS or a little baking soda in water if the burning is uncomfortable.

Other clues that you may have low stomach acid can be found on your standard blood tests called the CMP – or comprehensive metabolic panel and CBC – complete blood count. If you have one or more of these signs: chloride levels under 100, high or low serum protein or serum globulin levels, low phosphorous levels, especially with a vitamin D deficiency, high BUN levels of 20 or more, abnormal MCV, MCH, MCHC or below normal Hematocrit or Hemoglobin, indicative of iron deficiency, you may have low stomach acid.

And then there are several common reasons you may be low on stomach acid that you may already know about, including having had gastric surgery, having stomach cancer, and autoimmune gastritis (or an autoimmune attack on the parietal cells in your stomach that produce acid and intrinsic factor, which helps absorb vitamin B12), which causes pernicious anemia, which is a deficiency of B12. I was diagnosed with that issue early on in my gut heath journey, but no one suggested at that point that I may need to support my stomach acid. Since autoimmune diseases tend to occur in groups, if you have another autoimmune disease, it’s possible you have autoimmune gastritis as well and can asked to have your parietal cell and intrinsic factor antibodies tested. Finally, if you have H pylori, or Helicobacter pylori, you may have low stomach acid. I’ll dig into that a little bit more further down. Another sign for me is when clients tell me that when they eat meat, it feels like it just sits in their stomach. Sulfur smelling gas is also a possible sign of undigested protein and low stomach acid.

And of course GERD isn’t always related to stomach acid, but can be the result of upward pressure of gasses from an excess of bacteria in your small intestine, or small intestine bacterial overgrowth (SIBO), and undigested or malabsorbed carbohydrates. In my case, an intolerance to dairy, in particular casein, seemed to be at the root of my acid reflux, as it disappeared almost completely after I eliminated dairy from my diet. I knew I was lactose intolerant and took lactase enzymes when eating dairy and had already made the move to remove gluten, but the completely removal of dairy was key for me personally.

What is the cause of excess stomach acid?

For those people who do actually have excess stomach acid, one possible reason is Zollinger-Ellison syndrome (ZES), which is a rare digestive disorder that causes tumors called gastrinomas in the intestine, pancreas or both. Gastrinomas release the hormone gastrin, which prompts the stomach to produce too much acid. That’s one of the reasons why it is best to start to try to address these types of issues with a gastroenterologist, to make sure it’s not serious. If you get nowhere with that approach, then a functional medicine or naturopathic expert on gut issues may be in order.

Another common cause of excess stomach acid is an H. Pylori bacterial infection. Usually with a new infection, stomach acid increases, but then after the infection continues and increases, the damage to the stomach cells can lead to low stomach acid. This is caused by the release of an enzyme from H. Pylori called urease, which breaks down in the stomach into carbon dioxide and ammonia, causing burping and bad breath that are commonly associated with H. Pylori, and which neutralizes stomach acid.

You can also end up with excess stomach acid after going off of a PPI or H2 blocker. Common H2 blockers are Famotidine (Pepcid AC, Pepcid Oral, Zantac 360), Cimetidine (Tagamet, Tagamet HB) and Nizatidine Capsules (Axid AR, Axid Capsules).

And a couple other less common reasons for high stomach acid include gastric outlet obstruction and chronic kidney failure.

Is it a good idea to take PPIs for an ulcer?

In addition to their use in GERD, PPIs are also often prescribed to both prevent and treat ulcers, which are open sores on the inside of your stomach (aka a gastric ulcer), or an open sore on the inside of the upper portion of your small intestine, or your duodenum, (aka a duodenal ulcer). Together, both are referred to as peptic ulcers.

Symptoms of ulcers include

  • Burning stomach pain
  • Feeling of fullness, bloating or belching
  • Intolerance to fatty foods
  • Heartburn
  • Nausea

And some more severe but less common symptoms are:

  • Vomiting or vomiting blood — which may appear red or black
  • Dark blood in stools, or stools that are black or tarry
  • Trouble breathing
  • Feeling faint
  • Unexplained weight loss
  • Appetite changes

Because the main causes of ulcers are H. pylori and long-term use of NSAIDs and/or taking other medications along with NSAIDs, such as steroids, anticoagulants, SSRIs (or selective serotonin reuptake inhibitors, which are prescribed for anxiety or depression), or the drugs Fosamax or Actonel, getting off those medications through functional medicine approaches to the issues necessitating them is a necessary first step. And then for H. pylori, getting diagnosed and treating it. However, in the meantime, if you do have an active ulcer, taking PPIs is recommended and can prevent further damage and serious complications.

What is H. pylori and how do I know if I have it?

So, you may not be old enough to remember this, but I do. They used to believe that spicy foods and stress caused ulcers, which we have since learned isn’t exactly true. Drs. Barry J. Marshall and J. Robin Warren, Australian researchers, discovered in 1982 that H. Pylori was in fact the root cause of more than 90% of duodenal ulcers and up to 80% of gastric ulcers, for which they were awarded a Nobel Price for Physiology or Medicine in 2005, after being ridiculed and ignored by the mainstream medical establishment. 

The dilemma with H. Pylori is that doesn’t always cause ulcers and many healthy people have it in their systems with no problem. In fact, in developing countries, H. Pylori is found in over 80% of people, and about 20-50% have it in developed countries, but only 10-15% of people who have H. Pylori will develop peptic ulcers. The way that some strains of H. pylori cause peptic ulcers is by attaching themselves to the protective mucous coating of the stomach and duodenum, and weakening it, allowing acid to reach the sensitive lining beneath it, causing an ulcer to form. Left untreated, ulcers can lead to stomach perforation and bleeding and in extreme and untreated cases, death.

Now you should understand that only some strains of H. Pylori cause ulcers or gastric cancer, but not all, so if you have it, it’s important to find out whether your strain of H. pylori has virulence factors that can cause these complications. To find out, you can take the GI Map Test*, which currently costs $399 and is one of my favorite functional medicine stool tests, or an H. pylori profile, which is the H. pylori test with virulence factors from the GI Map, which is just $139 (reach out to me about accessing this test). You can also diagnose H. pylori, but not the strain, through a stool antigen test, which most doctors will order if you request it, a urea breath test, or a biopsy done with an endoscopy. However, in my experience, those biopsies always come up negative for my clients who then test positive using the GI Map’s PCR, or DNA-based test for H. Pylori. I like the GI Map because while it’s not usually covered by insurance, the information you get on it is worth its weight in gold. You can order it yourself online too, and I usually recommend it for my clients with any chronic GI issues, because it will tell you not only if you have H. Pylori and whether your amount of H. pylori is abnormal, it will also test for all other known gut pathogens, parasites, etc. as well as signs of gut dysfunction originating in your digestive organs.

Once you diagnose H. pylori, you can treat it either with the recommended regime of 2 antibiotics for a week plus a proton pump inhibitor (one of the rare uses for which I think a PPI is justified) or a course of herbal antimicrobials targeting H. pylori specifically. There’s also a new probiotic that helps treat H. pylori called Pyloguard, which you can find in my Fullscript Dispensary*.  

Are PPIs a good treatment for gastritis?

Gastritis is inflammation, erosion or irritation of the lining of the stomach which will often lead to a recommendation of a course of PPIs. It can be asymptomatic or can have symptoms such as

  • Indigestion
  • Nausea or recurrent upset stomach
  • Bloating, pain, vomiting, including vomiting of blood or material that looks like coffee grounds
  • Burning or gnawing feeling in the stomach between meals or at night
  • Hiccups
  • A low appetite
  • Black, tarry stools, indicative of blood in your stool

You can have an acute or sudden case of gastritis, or it can come on gradually and last a while, which would be considered chronic. But either way, if you catch it early, gastritis can be dealt with easily. However, left untreated, it can lead to a severe loss of blood and may increase your risk of stomach cancer. If you have evidence of blood in your stools like the black, tarry stools I mentioned, you should ask your doctor to do a fecal occult blood stool test.

Common causes of gastritis are alcohol abuse, H. pylori, other bacterial gut infections, viral infections, and bile reflux, or when bile backflows into the stomach from the bile tract that connects to the liver and gallbladder. It is also commonly caused by aspirin and NSAID use. When I was going through terrible sciatica, I ended up taking ibuprofen at the maximum recommended dose pretty much all day long, which ended in me having either gastritis or the beginnings of an ulcer. That was one scenario where I did take a PPI for a short time in order to reduce my stomach acid and give my stomach some time to heal, as I tried to find other solutions for my chronic pain. One product I can recommend if you have some type of physical pain like that that necessitates ongoing pain relief, is called Acute Pain Relief (find it in my Fullscript Dispensary*). It’s a Euromedica product with Curcumin and Boswellia that will help your acute pain by naturally decreasing inflammation.

Is it dangerous to take PPIs?

While a short course of PPIs is generally considered safe, long-term PPI use is very problematic. Because PPIs reduce your stomach acid by up to 99%, the result of that can be the development of even worse gut bugs like C. difficile, maldigestion of protein, B12 anemia (which I had) and other vitamin and mineral deficiencies, increased risk of fractures and osteoporosis and pneumonia.  A 2021 study by Arun Koyyada concluded: “. . . the use of long-term PPIs may lead to significant vitamin (B12 and C) and mineral (iron, calcium and magnesium) deficiencies which need gastric acid for their absorption and bioavailability.”

So if you think of each one of those nutrients, if you’re B12 deficient, you’ll see signs such as fatigue or numbness in your extremities that can lead to permanent nerve damage, a sore and red tongue, mouth ulcers, disturbed vision, irritability and depression. If you’re low on calcium, this can cause muscle spasms and impair bone growth and repair and lead to osteoporosis. If you’re deficient in magnesium, it can lead to heart arrhythmias, loss of appetite, fatigue, shaking, pins and needles, muscle spasms, hyperexcitability and sleepiness. If you’re deficient in iron, it can lead to extreme fatigue, weakness, pale skin, chest pain, fast heartbeat, shortness of breath, headaches, dizziness, lightheadedness, cold hands and feet, inflammation or soreness of your tongue and brittle nails.  

Because PPIs block the production of stomach acid, which helps break proteins down into aminos acids, when it is not present it stresses the enzymatic system of the pancreas and other digestive organs which are prompted to secrete enzymes in response to stomach acid levels and ultimately causes a decrease in the absorption of proteins. Because proteins and the amino acids that make them up are necessary for building the gut lining and pretty much any other type of cell, enzyme, hormone or neurotransmitter in the body, protein deficiencies can lead to  numerous, cascading and complex medical issues and the failure to rebuild the system that is used to digest protein. These issues can include mental health issues, immune suppression and imbalanced hormones.

A 2017 study, Adverse Events of Proton Pump Inhibitors: Potential Mechanisms, concluded: “Current evidence suggests that use of PPIs may be associated with negative outcomes by eliciting several different pathophysiologic mechanisms. While short-term PPIs could be considered effective and safe in adult patients with acid-related disorders, their long-term and often inappropriate use in patients carrying vulnerability to adverse events and/or high risk of drug-interactions should be avoided.”

And that hits the root of the problem, the indiscriminate prescription of PPIs when they aren’t indicated medically at all, which happens in 33% of cases, or outside of the current guidelines, in 54% of cases. This isn’t much different from the antibiotics problem, where they are prescribed indiscriminately because people go to the doctor with a problem that conventional, Western medicine doesn’t know how to solve and the doctor feels obliged to do something and so just prescribes an antibiotic.

Other serious side effects that have been linked to PPIs include dementia, kidney disease, myocardial infarction, pneumonia and stroke. A study with US veterans found 45.2 excess deaths per 1000 patients amongst those taking PPIs due to cardiovascular disease, kidney disease and gastrointestinal cancer. They also found a greater number of infections, parasitic diseases, neoplasms or new and abnormal growth of tissue in some part of the body, and genitourinary disease associated with PPI use. For kidney disease, studies consistently suggest that the use of PPIs may be associated with an increased risk of adverse kidney events, especially in the elderly (with long-term PPI use and pre-existing kidney disease). Another additional question being studied is whether chronic PPI use can lead to the onset of gastric cancer. The abrupt discontinuation of PPIs is also related to increased gastric acid production above pre-PPI treatment levels, a phenomenon called acid rebound.

So my advice is, if you need something to give you immediate relief, try a simple acid reducing medication like TUMS, or baking soda in water, an H2 blocker, or if you must take a PPI, my recommendation is to follow diligently the instructions on the package that says not to take them for more than 14 days. If your problem doesn’t resolve in those 14 days, you may need to look harder for your root cause.

If you have follow up questions, a great place to ask them is in my Facebook group called Gut Healing.  And if you’re struggling with gut and/or other health issues and need some help, I offer a free, 30-minute breakthrough session to talk about your issues and to see if health coaching might help you resolve them.

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