Gastro-esophageal Reflux Disease (GERD) is a functional disorder where the lower esophageal sphincter, the gate between the esophagus and the stomach, does not close sufficiently, or opens when it shouldn’t, thus allowing backflow of stomach contents.
In normal function, food moves down the esophagus via peristalsis, the valve relaxes to allow food to pass into the stomach and then immediately closes again. If the valve doesn’t close completely, or relaxes when it shouldn’t, reflux occurs. Since the contents of the stomach are highly acidic this backflow is painful and over time can cause damage to the lining of the esophagus. Almost everyone experiences occasional heartburn, but when it occurs regularly several times a week, and causes chronic irritation of the esophagus, this can be a sign of a more serious condition – GERD. The most common symptom of GERD is heartburn. Other common symptoms are: regurgitation (not the same as vomiting), frequent burping, a sour taste in the mouth, increased saliva production, and dysphagia – the feeling of a lump in the throat that may effect swallowing and can trigger a chronic throat-clearing cough.
An estimate from the American Gastroenterological Association suggests that about 33% of Americans suffer from GERD. Although GERD can occur at any age, the risk increases after 40.
GERD is usually diagnosed based on symptoms. Diagnostic tests like endoscopy, testing of esophageal acidity, pressure testing of the lower esophageal sphincter, and x-ray with barium swallow are often reserved for cases where the patient is not responding as expected to medication, or to exclude other conditions like Barrett’s esophagus or esophageal cancer.
Some common triggers for heartburn and reflux include spicy foods like garlic and onions, fatty or fried foods, and acidic foods like tomatoes or citrus. Coffee, soda, and alcohol increase production of stomach acid, which doesn’t help the situation. Peppermint, chocolate, alcohol, and cigarette smoking all cause the lower esophageal sphincter to relax so they can make reflux worse. Obesity, pregnancy, and a hiatus hernia, a condition where a part of the stomach protrudes upward through the diaphragm, all increase the pressure on the stomach and can contribute to the development of GERD.
There is no cure for GERD, the goal is to limit damage and reduce symptoms. There is an operation to tighten the lower esophageal sphincter, but it is not a first-line treatment. The use of proton pump inhibitors (PPIs) like Prilosec or Nexium is the current standard of care for GERD. PPIs reduce the production of stomach acid to a higher degree than the previous generation of medications (Histamine-2 blockers), thus allowing a greater degree of healing.
In general the proton pump inhibitors offer good symptomatic relief from GERD; however, there are several issues that may be of concern to people on extended courses of treatment. In order to promote healing of ulcers that occur in the esophagus, the environmental acidity needs to be substantively reduced for 4 to 12 weeks. PPIs are good at this. Unfortunately these ulcers can become chronic and require repeated courses of treatment. There is evidence to suggest that extended use of PPIs may not be such a great thing. Effective long-term suppression of stomach acid may result in a stomach environment with inadequate acid for the digestion of proteins and for the absorption of key nutrients including vitamin B12 and calcium. Over time this may lead to vitamin deficiency and interfere with the cycle of bone re-absorption and bone creation, resulting in greater bone fragility. This may be of particular concern to menopausal women who are already struggling with issues of bone loss. Extended use of PPIs has also been linked to an increased incidence of gastric polyps. There is also evidence that suggests that extended PPI use can result in dependency, with substantive rebound symptoms upon termination.
Traditional Chinese Medicine (TCM) looks at GERD as a symptom of a more systemic imbalance. In TCM the symptoms of heartburn and reflux are almost always understood as a conflict between the liver and the stomach. In Chinese medicine, the liver is seen as being in charge of keeping everything in the body (blood, energy, emotions, digestion) flowing smoothly in the correct directions. When the liver is taxed beyond its comfort zone, often as a result of protracted stress, it is unable to keep everything flowing smoothly and it rebels. Often the direction of this rebellion is sideways into the stomach. The stomach’s normal direction of energy flow is downwards. When the rebellious energy of the liver (or the undifferentiated energy of a first trimester fetus) impacts the stomach, it causes the energy in the stomach to rebel upwards, potentially leading to chronic symptoms and signs like a thick greasy tongue coat, burping, heartburn, and reflux. The feeling of a lump in the throat, often with a throat-clearing cough, is called “plum pit qi” and is classic sign of liver qi stagnation.
The big difference in how we treat these symptoms in TCM versus Western Medicine is that an understanding of the way stress affects the body and the development of pathology is built into the very foundation of TCM theory. In our differential diagnosis, we look at the effects of stress on the relationships between organ systems and the imbalances that arise as a result. Then we treat those imbalances, as well as the presenting symptoms.
The treatment strategy for symptoms like heartburn and reflux will vary depending on the specific presentation of the individual. In general, the idea is to sooth and regulate the liver, dissipating the stress that causes it to beat up on its neighbor the stomach, restore the normal downward flow of stomach qi, and clear the heat and transform the dampness that tend to accumulate when the stomach qi is disrupted. Both acupuncture and Chinese herbal medicine offer effective treatments for these objectives. Depending on preference, lifestyle, and severity of symptoms you might chose either or elect to do both. You might also chose to use either modality as an adjunctive therapy to your Western medication to give you better control of break-through symptoms, to reduce your medication dose, or to mitigate side effects of your medication.
Sources:
The Merck Manual – Second Home Edition, Pocket Books 2003
The Treatment of Modern Western Medical Diseases with Chinese Medicine – Bob Flaws & Phillippe Sionneau, Blue Poppy Press 2001