Acid Reflux: Why (almost) everything you know about gastroesophageal reflux disease (GERD) is wrong

February 2024

My interest in acid reflux and heartburn peaked after my then 3 week-old infant daughter started experiencing reflux episodes, where she would projectile vomit, cry for hours, and grunt and cough whenever placed on her back to sleep. We were told it was “just colic” by our provider and that it was normal. I felt quite helpless because it was clear she was in pain. 

Fast forward two months and my younger brother, 35 at the time, tripped and fell and broke his femoral head, requiring hip replacement surgery. He was lucky he did not lose his limb, as he waited four days for a bed in hallway-healthcare Ontario, and had started to show signs of necrosis to the area. He has a long history of gastroesophageal reflux disease (GERD) and taking proton pump inhibitors (PPIs) for decades. It was only later did I question whether being on PPIs long-term affected his bone mineral density, as it did not make sense why a younger adult had weak bones, knowing that long-term PPI use is associated with increased risk of fracture.

In December, I presented to more than 500 clinicians about gastroesophageal reflux disease (GERD). I, alongside my three colleagues, dove into the research and guidelines on GERD, including everything from the causes of heartburn and regurgitation, to the pathophysiology, to the research behind medication and evidence-based supplement options.

Reflux, to a degree, is normal

Reflux, to a degree, is normal. There can be up to 40 reflux events a day that do not cause symptoms or tissue injury. They happen as a normal part of digestion and we don’t feel them. 

GERD, on the other hand, is a chronic upper GI disorder that occurs when stomach contents reflux into the esophagus in inappropriate amounts or frequency, resulting in bothersome symptoms or complications. It is this shift in acid exposure that is the main pathophysiological mechanism for GERD. 

1 in 5 people have GERD. It’s a very common condition that affects many Canadians. By definition, however, GERD is a bit misleading in that it is not one condition or one set of symptoms. For that reason, it is a “heterogeneous disease”.

True GERD can either be erosive — where there is damage to the esophagus mucosa — or non-erosive, where there is not damage to the tissue. But many don’t know that someone can have all the symptoms of GERD without having true GERD. Reflux and heartburn actually exist on a spectrum, where these symptoms can be due to altered physiology OR altered perception. This means that someone’s heartburn and reflux may be the result of a disorder of gut-brain connection where they sense symptoms of acid but their acid levels and reflux frequency are all normal. In fact, it’s approximated that of all patients with acid reflux symptoms, only 37 percent of them have true GERD. 34 percent have functional heartburn, 15 percent have reflux hypersensitivity, and 14 percent are unclassified [1].

Sometimes reflux is a disorder of gut-brain interaction (DGBI)

The categories “reflux hypersensitivity” and “functional heartburn” may explain why not all patients respond to PPIs to control their symptoms, and not all patients with heartburn and regurgitation have findings on their endoscopy.

Reflux hypersensitivity and functional heartburn are both disorders of gut-brain interaction (DGBI). You may be most familiar with irritable bowel syndrome which is also a type of disorder of gut-brain interaction; there are 22 disorders in total. Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease, where RH is a form of visceral hypersensitivity that occurs when normal acid or non-acid reflux levels cause symptoms resembling GERD. Similarly, functional heartburn is a disorder characterized by GERD-like pain or discomfort unrelated to acid or non-acid reflux events.

The challenges with gerd assessment and treatment

There are some assessment and diagnostic challenges for patients presenting with reflux, regurgitation, and heartburn. First, the Canadian guidelines from the Canadian Association of Gastroenterology (CAG) haven’t been updated in 20 years. The current guidelines, published in 2004, is not reflective of the ROME-IV diagnostic criteria which is the assessment criteria used for reflux hypersensitivity and functional heartburn. The guidelines also do not mention that patients need to discontinue their PPI for two weeks prior to their endoscopy or else risk inaccurate results. The American guidelines from the American College of Gastroenterology (ACG) were updated in 2022 and are much more comprehensive and up-to-date [2], but here in Canada, we tend to follow Canadian guidelines.

Second, not all patients have completed an endoscopy to determine if there is tissue damage from acid exposure. The American College of Gastroenterology recommends 24-hour pH monitoring which is rarely used in Canada and I have yet to meet a patient who has had this test. A 24-hour pH monitoring test would be able to differentiate between non-erosive esophagitis, reflux hypersensitivity, and functional heartburn, and an endoscopy would be able to evaluate the extent of tissue damage, if any, which is important when a patient has more serious erosion like “LA Grade C or D” esophagitis or Barrett’s Esophagus. 

Third, there are no universal guidelines on when to stop a proton pump inhibitor (PPI), the first line pharmacological therapy for the control of GERD [3]. PPIs are very effective. They can heal the tissue after about eight weeks of use. But they also come with potential side effects and long-term risks. Adverse effects may increase with longer use of PPIs, and include gastrointestinal side effects like increased risk of C. diff infection and reinfection, magnesium malabsorption, and increased risk of chronic kidney disease.

If you have heartburn and reflux and you’re wondering why your symptoms are still persistent,  it may be time to book with an evidence-based gut-focused naturopathic doctor. “Take this medication and don’t come back” isn’t a good game plan. It’s important to start exploring whether you’re a candidate to discontinue your medication and whether this could be a disorder of gut-brain interaction like reflux hypersensitivity or functional heartburn, and discuss strategies that address both the gastrointestinal system and the way the brain communicates to the digestive tract.

Dr. Dominique Vanier is a naturopathic doctor in Burlington, Ontario. As a regulated health provider, she is registered to see patients in Ontario both virtually (online) and in person.

References:

  1. Zhang M, Chen M, Peng S, Xiao Y. The Rome IV versus Rome III criteria for heartburn diagnosis: A comparative study. United European Gastroenterol J. 2018 Apr;6(3):358-366. doi: 10.1177/2050640617735084. Epub 2017 Sep 27. PMID: 29774149; PMCID: PMC5949975.

  2. Katz, Philip O., Kerry B. Dunbar, Felice H. Schnoll-Sussman, Katarina B. Greer, Rena Yadlapati, and Stuart Jon Spechler. 2022. “ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease.” The American Journal of Gastroenterology 117 (1): 27–56. https://doi.org/10.14309/ajg.0000000000001538.

  3. Choosing Wisely Canada. Bye Bye, PPI: A Toolkit for Deprescribing Proton Pump Inhibitors in EMR-enabled Primary Care Settings. Version 1.3, May 2019.