Upper Digestive Issues: Gastritis, Ulcers, GERD and Low Stomach Acid

Upper Digestive Issues: Gastritis, Ulcers, GERD and Low Stomach Acid

The problems I address in this article happen north of the intestines in the stomach or in the first part of the small intestine, called the duodenum. While some of these are dealt with effectively using traditional medical care, others will be missed by your traditional doctor, or will become advanced and require a functional medicine approach because they’ve been left so long unattended that they’ve provoked problems in your gut microbial balance or because their origins are bacterial gut infections that traditional doctors don’t know how to look for or treat.

Let’s start with gastritis. This is a first line problem where your stomach is bothering you. 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, or
• Black, tarry stools, indicative of blood in your stool

All this means that you have inflammation, irritation and/or erosion of the lining of the stomach. And 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 is, if you catch it early, gastritis can be dealt with pretty easily. However, left untreated, it can lead to a severe loss of blood and may increase your risk of stomach cancer.

A lot of people will just figure out they have gastritis from the pain and do something about it without seeing a doctor. But if you have a chronic case and taking antacids isn’t doing the trick, you may see a doctor, who may do an upper endoscopy, and likely blood tests, such as checking your red blood cell count for anemia, or possibly check your B12 levels to see if you have pernicious anemia or a B12 deficiency, which can result from low stomach acid, which can give you some of the same symptoms as gastritis. And if you have evidence of blood in your stools like the black, tarry stools I mentioned, your doctor may do a fecal occult blood stool test. And if your doctor is on the ball, he or she will also check for H. Pylori or helicobacter pylori, which is a bacteria that can cause these symptoms. I’ll touch more on that later. However, your doctor’s test could miss H. Pylori, so often people will end up needing better testing to verify that their problem was H. Pylori all along.

Some of the causes of gastritis are within your control, so if you are using alcohol excessively, stopping or reducing your use is one treatment. If you have an eating disorder, chronic vomiting will also cause gastritis, so you may need to get professional help with that. And of course our old friend stress can also cause gastritis, so either eliminating your sources of stress or mitigating them may help. And taking NSAIDs or non-steroidal anti-inflammatory drugs, including acetylsalicylic acid, which is the drug in medicines like Aspirin, ibuprofen (which is in Advil and Motrin), diclofenac (which is a topical pain cream and is found in a product called Voltaren) and naproxen sodium, found in Aleve, is another way to end up with gastritis, so if you can stop those or reduce your use, that may help. You can take Acetominaphin without these negative side effects, although I’m well aware that it doesn’t take care of the same problems.
The last possible causes of gastritis that will require professional help are H. Pylori or other bacterial or viral infections, and bile reflux, which is a backflow of bile into the stomach from the bile tract (which connects to the liver and gallbladder).

If you are diagnosed with gastritis, one treatment you’ll likely be offered by your doctor is to take either antacids and other drugs (such as proton pump inhibitors, also known as PPIs or H-2 blockers) to reduce stomach acid. Some examples of these are Nexium, Protonix, Aciphex, Omeprazole, Prilosec and Prevacid, and these are offered over the counter, which makes them look innocent, but let me warn you, as someone who took them continuously for like 15 years, they are not innocent. These drugs will reduce your stomach acid by up to 99% and the end result of that can be the development of even worse gut bugs, maldigestion of protein, B12 anemia, leaky gut, and ultimately, autoimmune disease, all of which I believe I developed after long-term PPI use. The only one that wasn’t definitely diagnosed for me was the maldigestion of protein, but I had all the rest. If you have to take a PPI, my recommendation is to follow the instructions on the package that says not to take 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. In my case, my root cause of bloating and an incessant cough that was coming from stomach acid in my esophagus, was an intolerance to dairy. I thought I was only lactose intolerant and dutifully took my lactose digestant tablets when I ate dairy, but it turns out I was also intolerant to casein. When I completely cut out dairy, my 15 years of acid reflux disappeared. It was a sad day, but as my French friend said to me about a year earlier, “if you have to take a pill to eat something, do you think you should be eating it?” Those words rolled around in my head for about a year before I was willing to face the loss of my beloved dairy, but I haven’t looked back and have learned to replace the creamy, salty, umami of dairy with avocado or just make different dishes that don’t require dairy. And I occasionally cheat and take many pills to digest gluten and dairy for Neopolitan pizza or burrata cheese, but that’s about it.

Back to treatments your doctor may recommend for gastritis, this could include recommending you avoid hot and spicy foods, eliminate gluten and/or dairy, which are two of the most likely dietary culprits for these kinds of issues, or if your issue if pernicious anemia, vitamin B12 shots or like I take, sublingual tablets. And finally, if your root cause is H. Pylori, and a traditional doctor finds, it, you’ll likely end up on a cocktail of several antibiotics plus PPIs, which may mess up your gut microbiome even more and cause you long-term problems, so I wouldn’t recommend that approach. And I’ll address the best way to deal with H. Pylori under the topic of ulcers.

Some more functional medicine type treatments for gastritis include taking DGL* or Deglycyrrhizinated Licorice before meals, which helps with the mucus production in your stomach and intestines and helps coat and protect them. And the probiotic Lactobacillus rhamnosus GG, which is found in Culturelle* and other probiotics, has also been found to help with gastritis.

But the good news is that most people with gastritis improve quickly once treatment has begun, so the moral of the story is, don’t ignore your body’s early signals that something is amiss in your gut because it can get worse.

Left unchecked, some gastritis, depending on its root cause, can turn into an ulcer, which is an open sore 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 of these are referred to as peptic ulcers. The main causes of these, like with gastritis, 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.

Symptoms of ulcers include:

• Burning stomach pain
• Feeling of fullness, bloating or burping
• 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

You may not be old enough to remember this, but I do. They actually 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.

But as I mentioned, one other primary cause of ulcers is prolonged use of NSAIDs, like Ibuprophen. I recently had the misfortune of experiencing this during my ongoing bout of sciatica because I can’t survive without some type of pain relief. I was taking 2 Ibuprofen every 4 hours (which was what my doctor described as the maximum safe dose, without any warning about ulcers, although of course I knew better). First it felt like an acidy feeling in my chest, then it felt like a burning or slight discomfort in a particular place in my stomach after taking Ibuprofen. I was so desperate for pain relief I kept taking Ibuprofen for at least 7-10 days after this sensation started, but eventually knew I had to stop or I’d end up with a bleeding ulcer. I have since had to switch to Acetominaphin, even though it’s not as good for my type of pain, but I really had no choice. Now I reserve the Ibuprofen for only my worst days. And the good news is that I was able to reverse this problem relatively quickly by taking a PPI, Omeprazole, for about 10 days along with the probiotic Culturelle, which is also recommended for ulcer prevention, and my symptoms resolved quickly. The bad news is, I’m on another drug to help relax my muscles called Tizanadine, which is starting to cause an acidy stomach, so I may have to dip back into the PPIs, or stop the Tizanadine, so I’ve got a bit of a dilemma, as I imagine many of you have when faced when you’re faced with the choice of taking your needed drug or having digestive issues, which was something I was a bit more flippant about when it wasn’t my body, and which I can now totally appreciate, as I try to control my pain while trying to resolve the root cause of my sciatica.

Getting back to our old friend, H. Pylori, which is the primary cause of ulcers, the dilemma is that it 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. Some strains of H. Pylori cause gastric cancer, but not all, so if you have it, it’s important to find out which strain you have and if it’s a problematic one, which you can find out through the GI Map Test, which costs about $400, and is used by functional medicine practitioners. Unfortunately, it’s not covered by insurance, but 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 upper GI issues, because it will tell you not only if you have H. Pylori, but if you have what’s called virulence factors, or the really bad strains of H. Pylori, and whether your amount of H. Pylori is abnormal, and will also test for all other known gut pathogens as well as signs of gut dysfunction originating in your digestive organs.

The way that H. pylori causes peptic ulcers is by attaching itself 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, it can lead to stomach perforation and bleeding. Ironically, some studies show H. Pylori can be protective as well against gastro-oesophageal reflux (aka GERD) and oesophageal carcincoma, and the former is documented in fascinating detail in Martin Blaser’s book “Missing Microbes” that made me want to go out and get H. Pylori, because of the GERD that plagued me for years. Dr. Blaser, who had H. Pylori but was asymptomatic, cleared it out with antibiotics, then found himself with GERD, then reinoculated himself with it. It turns out that certain strains of H Pylori (cagA+ ones) can reduce the acidity of the stomach (thereby raising its pH) which can prevent GERD, Barrett’s oesophagus and adenocarcinoma (a kind of cancer) of the oesophagus.

However, what I have seen in clients with H. Pylori is a sequence of events that leads to problems. First you see a decrease in 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 or hydrochloric acid, or HCl. HCL prompts the release of bile, which helps metabolize fat in the small intestine, so you can get fat maldigestion, which can lead to nutrient deficiencies. If your stool is pale or floating, that may be because you don’t have enough bile production.

As a result of low stomach acid, you get a rise in pathogenic bacteria or overgrowths of commensal or beneficial bacteria that are not killed off in an acidic stomach, such as Escherichia, including certain pathogenic strains of E Coli, Clostridia, including Clostridia Difficile, which you often see people getting after hospital stays and which causes explosive and frequent diarrhea, Enterococcus, including Enterococcus faecalis and faecium, streptococcus, and overgrowths of yeast such as candida albicans, candida glabrata or other fungi and a high ratio of the phylum firmicutes to bacteroidetes or other more pathogenic strains of H. Pylori. Eventually this can turn into an increase in stomach acid, which will also cause symptoms of acid reflux, bloating, gas, etc.

Low Stomach Acid
Now I want to stop for a minute to make sure you understand that low stomach acid can cause the same symptoms as too much stomach acid, but traditional doctors will almost always assume that your symptoms are coming from too much stomach acid, diagnose you will GERD and prescribe PPIs. The normal pH of a stomach for healthy protein digestion is 1.5-2.2. And that proper pH is a trigger for contraction of the lower esophageal sphincter, which is just above the stomach. This protects the soft, delicate tissue of the esophagus from the harsh acids in the stomach. If your stomach acid is too low, the sphincter may remain open, letting acid up into your esophagus, causing GERD symptoms like burning or an incessant cough, which often prompts people to take antacids or PPIs. These medications can exacerbate the problem by preventing proper digestion of foods, especially protein, which you need HCl to digest, and stressing the enzymatic system of the pancreas and other digestive organs, which are prompted to secrete enzymes in response to stomach acid levels. This can lead to calcium deficiencies, iron deficiencies, B12 deficiency, Vitamin A deficiency (which leads to increased inflammation and gut damage), and protein deficiency, all of which lead to other problems in the body.

When you have a low stomach acid situation brought on by H. Pylori or other reasons, like aging, you will often then see low pancreatic elastase 1 on the GI Map test, which is a digestive enzyme secreted by the pancreas. You can also see this decrease in pancreatic elastase 1 for other reasons, such as gallstones and a vegetarian or vegan diet.

Now back to the question of whether stress is a potential cause of ulcers. The reality is that it probably is, but indirectly. While H. Pylori may be ultimate culprit, given that so many people have H. Pylori and no ulcers, the question is, “why do some people get them?”. So here is the route that this commonly follows. First, our bodies’ first line of defense in the mucous membranes, segretory Immunoglobulin A or SIgA decreases in response to chronic stress. As a result, our gut defense systems are down, allowing the overgrowth of pathogenic or opportunistic bacteria like H. Pylori, which can lead to an ulcer. Or it can lead to decreased stomach acid and other overgrowths as I mentioned before.

So the better way to deal with H. Pylori, rather than taking antibiotics, is to take mastic gum* which is quite effective in treating H. Pylori, along with probiotics of various types, DGL*, and slippery elm*, to help coat your stomach. And if you can tolerate it and it appears you have low stomach acid, it helps to supplement with Betaine HCl*, or stomach acid, using a Betaine HCl challenge test approach, which I’ll describe in just a minute.

Okay, finally let’s finish up the topic of GERD or gastro-oesophageal reflux, which again is when the lower esophageal sphincter lets acid up into the esophagus. We’ve already touched on some possible causes, including low stomach acid and H. Pylori, so other possible causes are a hiatal hernia, pregnancy, scleroderma, which is an autoimmune disease, obesity, smoking, alcohol usage and certain prescription drugs. So it may be that you have excess stomach acid and not low stomach acid, in which case a short-term (meaning no more than 14 day) course of PPIs may be called for, but you should really only use them when necessary and symptomatic, and then start to try to figure out the root cause of your excess stomach acid and address it. So if you have no other possible root cause as I just mentioned and are negative for H. Pylori, you can start by trying the Betaine HCl challenge to see if you have low stomach acid. The way you do that is to start with one capsule per meal with animal protein (they typically are sold in the 500-750 mg range) then increase your dosage by 1 capsule/meal every 2 days until you feel heartburn or a warmth in your stomach (going up to as many as 5 capsules), then back down to previous dose. If you immediately feel a burning, then it may be you have excess stomach acid or perhaps a hiatal hernia or some other issue. You can take an antacid or some baking soda to neutralize the acid if it’s bothering you. But there are some contraindications for using Betaine HCl, which include Barrett’s esophagus, diagnosed malformation of the lower esophageal sphincter, a history of stomach ulcers, any diagnosed disease or pathology of the pancreas, or if you’re taking NSAIDs or have a diagnosed blood-clotting disorder. One alternative to taking Betaine HCl is to have 1-2 tbsp. of apple cider vinegar or lemon juice mixed in water 10-15 minutes before meals. But again, if you have a diagnosis of Barrett’s esophagus, esophageal strictures, or reflux esophagitis, you shouldn’t use these either. In that case, your best bet is just to try digestive enzymes* that don’t include Betaine HCl, but if you do want to try the Betaine HCl* approach, it’s best to find one with pepsin, which is an enzyme normally secreted by the cells in your stomach.

If you want more help with your gut, autoimmune or other health issues, you can set up a free, 30-minute Breakthrough Session with me (Lindsey) to share what you’ve been going through and decide whether my 5-appointment gut health coaching program or a longer program for autoimmunity or weight loss is a good fit for you. Individual 1-hour consultations may be scheduled directly here.

This information isn’t intended to diagnose or treat disease but is for educational purposes only. Please consult with your health care professional before acting on any of this information.

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