Q: what’s the difference between heartburn, acid reflux, and GERD?
A: heartburn is the nickname for acid reflux. Chronic recurring acid reflux is called GERD (gastroesophageal reflux disease).
Q: what causes heartburn (the feeling)?
A: in plain English, heartburn is the term to describe the situation where stomach acid sloshes back up into the esophagus (your throat). It hurts.
Q: isn’t your digestive system designed to handle stomach acid?
A: No, not generally. Very specific parts of it digestive system are, such as the stomach and the duodenum, but these parts have specific things that protect them against getting destroyed by the stomach acid – for example, extra mucus and an extremely high regeneration rate for the cell layers that get torched.
Q: how come stomach acid doesn’t destroy the tissue after the stomach?
A: after the stomach (in the first part of your small intestine), stomach acid is quickly neutralized by an alkaline compound produced by your pancreas, bicarbonate. Yet another reason to be nice to your pancreas.
Q: how about prior to the stomach? How does the (healthy) stomach keep acid from sloshing up into the esophagus?
A: as you can imagine just from feeling the food go down as you swallow, your entire GI tract is strewn with various “gates” that stopped swallowed food (“chyme”) in certain compartments and then move it forward. The stomach has two gates (“sphincters”) that, when the person is healthy and they are doing their job, keeps swallowed food, and stomach acid, locked into the stomach for an acid bath.
Q: so, you’re saying that heartburn happens when this “gate” at the top of the stomach fails? And stomach acid sloshes back up?
A: That’s correct. So the next question is…
Q: what causes the sphincter, the gate, to fail?
A: from my understanding, there are three main scenarios where this happens: first, if something partially paralyzes the stomach (very rare), second, if backwards pressure forces open that gate (regurgitating swallowed air, which, although it might happen with some regularity, necessarily be chronic), and third, if the stomach, including the sphincter, becomes excessively irritated. This last scenario is what causes chronic heartburn – GERD. The other two might occasionally happen, but unless the acid so intensely damages the sphincter that it causes lasting irritation, only the third scenario will happen with any regularity in most people.
Q: so there could be multiple causes, but for somebody who is experiencing this chronically, it’s almost certainly because the stomach is irritated for whatever reason?
A: That’s correct. And of course the next question is…
Q: what irritates the stomach this way?
A: think about how your stomach operates: automatically. You don’t monitor your stomachs status, ordering your stomach to shift things into the small intestine, etc. Rather, you simply chop chop, swallow swallow, and go about your business. As luck would have it, so lucky! Your stomach is at the crossroads of a complex interconnection of nerves, chemical processes, etc, that provide fine-tuned feedback which enable your stomach to operate autonomically. When that powerful get fine tuned feedback loop is disrupted, your stomach is unable to function optimally, and thus becomes irritated. Specifically, this happens in relation to the stomachs function as an acid bath for swallowed food. As we have already mentioned, the stomach is designed by God to blast food with powerful acid. If for some reason the stomach is hindered by not having enough acid, the swapped food will be insufficiently processed by this acid bath. Instead of being torn apart and moved along, as it should be, the food will remain in the stomach and more or less the same state that it was swallowed. Being unable to digest the food correctly will cause irritation to the stomach, because although the stomach is designed to handle acid, it is not designed to be a holding chamber for undigested food. In other words, low stomach acid will prevent the stomach from doing its job, which will lead to undigested food sitting in your stomach, which in turn irritates your stomach. The insufficiently digested food is not ready for transit, but since it is irritating the stomach, the stomach will move however it needs to move in order to get that food out. These spasmatic motions result in stomach acid being squeezed up into the esophagus, resulting in the feeling that we call heartburn.
Q: so you’re saying that heartburn is caused only by low stomach acid, and the stomach’s response to undigested food?
A: not necessarily; but this is by far the most common scenario. Theoretically, there could be other things that irritate your stomach, including too much stomach acid, or even a one time we splash of stomach acid causing long-lasting injury and the esophagus. However, too much stomach acid is usually unlikely candidate, given that it is much easier to inhibit stomach acid than overdo it. Not only that, but strong stomach acid is typically a sign of health and vitality, as opposed to the other way around. Additionally, the stomach is well equipped to handle stomach acid, and it takes quite a bit of excess stomach acid to actually begin irritating it.
Another cause is unfriendly bacterial colonization – H. pylori infection, or ulcers generally. But these latter things tend to be effects, not causes – in other words, longstanding injury from improperly digested food allows for an opportunistic bacterial infection or ulcer.
Q: so wait: You’re telling me the opposite of what I’ve always read; that this is caused by too much stomach acid. You’re saying it’s caused by too little stomach acid. Correct?
A: almost always, yes.
Q: okay. So if that’s the case, why would it help to take a bicarbonate like Tums? I’ve done that before, and it’s helped.
A: we should be specific here. When you say it’s “helped,” what you mean is that the ouch feeling goes away. That’s not necessarily conclusive: If you pop a painkiller no longer feel pain, that doesn’t mean that the underlying infection or injury is gone away. All it means is that the feeling has been disabled. Think about the above scenario: if your stomach is splashing stomach acid up, and you take bicarbonate, that will indeed neutralize the acid and quickly reduce pain. However, it will also ensure that whatever undigested food is in your stomach will remain there, continuing to irritate the stomach. You won’t feel this irritation, at least with any intensity; you only noticed this at all when stomach acid splashed up into your esophagus. However, you’ve now done the worst thing possible for your stomach: you neutralized the stomachs acid, ensuring that the food will continue to sit there, improperly digested, and irritate the stomach. Stomach gas splashing up your esophagus is problematic; But the root of that problem was low stomach acid resulting in undigested food irritating your stomach. Neutralizing your stomach acid will only ensure that the food sits there longer, perhaps even fermenting, irritating that cell lining that is meant to accommodate strong acid, not raw food. In other words, taking bicarbonate will temporarily alleviate the feeling, but perpetuate the problem long-term.
Q: why long term?
A: think of this in terms of injury. If you get sunburned, you should probably avoid strong sun for a few days. It’s as if we got sunscreen, then sprayed some kind of anesthesia on it so we didn’t feel the pain, and remained in the sun. Neutralizing your stomach acid so that it cannot acidify the remainder of the swallowed food ensures that more damage and irritation will continue to happen.
The same is true, except even more so, multiplied, with H2 blockers or, even worse, proton pump inhibitors. Both of these inhibit your stomach’s ability to produce stomach acid, PPIs do this very intensely for a very long time.
By now, you can see why this is a very bad thing: everything you eat will be insufficiently digested, and therefore irritable to your stomach, and this continued irritation will ensure perpetual unsolvable GERD.
Q: so, what you’re saying is that I should actually be looking to increase my stomach acid production if I have heartburn?
A: absolutely. Instead of neutralizing your stomach acid, give your stomach what it needs, and take a shot of apple cider vinegar – If there is a food that you know is likely to trigger your heartburn, take a shot of apple cider vinegar before you eat that food. Note that the usual suspects for healthiness – eating properly, exercising, sleep, etc, well almost certainly increase your stomach acid production. Another option here is to eat bitters – wormwood, gentian root, dandelion leaf, etc. These of course have digestive benefits even beyond stomach acid.
Q: I’m a little bit unsure, because everything I read says it’s because of too much stomach acid. How would I know for sure?
A: The easiest way is of course to stop doing the thing that you know doesn’t work, and try something else. Like trying vinegar or bitters before eating. But another way is to go by a jar of BetaineHCL. This is an extract, typically of wheat germ (watch out celiacs), that will stimulate your stomach acid response. If you have high stomach acid, you’ll take one or two of these, and you’ll feel it burn immediately. If you have low stomach acid, however, you’ll be able to take three, four, sometimes as many as a dozen, without feeling any burn. This is an easy way to diagnose in real time, and you may find that BetaineHCL winds up being your weapon of choice here.
