Rational Wellness Podcast 030: Gastroesophageal Reflux with Dr. Michael Ruscio

Dr. Michael Ruscio speaks with Dr. Ben Weitz about Gastroesophageal Reflux Disorder.  Dr. Weitz gave an introduction to the topic, explaining that GERD occurs in up to 20% of Americans and is marked by the contents of the stomach coming up into the esophagus and creating a burning sensation.  There could be vomiting, a chronic cough, chronically bad breath, and possibly erosion of the teeth.  This can eventually lead to chronic inflammation of the esophagus, esophageal strictures (narrowing of the esophagus), Barrett’s esophagus, which is a pre-cancerous condition, and can even lead to esophageal cancer.   It is believed that the cause of GERD is a weakening or dysfunction of the lower esophageal sphincter that normally prevents bile acids, pancreatic enzymes, and stomach acid from travelling up from the stomach into the esophagus, where they can cause a burning and inflammation of the sensitive esophageal tissues.  This is why the primary surgical procedure for GERD is the Nissen fundoplication, in which the upper part of the stomach is wrapped around the lower esophageal sphincter to help strengthen it.  But from a Functional Medicine perspective, this definition of GERD does not help us very much, because we need to know what the underlying cause and what other factors it is related to.  This is why I have asked Dr. Michael Ruscio to help provide some clinically useful information. Dr. Ruscio is a doctor of chiropractic, a Functional Medicine practitioner, a researcher, and an educator, lecturing all around the world on the gut and thyroid.

3:22  Dr. Ruscio, what are some of the main factors that lead to gastroesophageal reflux? Dr. Ruscio explained that he would like to walk us through a four part intervention hierarchy that will help to codify the different mechanisms and treatments. We should imagine a pyramid and start with the base and address the least invasive and most common items first, such as diet. At the apex of the pyramid are the most invasive interventions, such as surgical procedures. We’ll start with diet, then we’ll go to dysbiosis, the third will be stomach acid levels, and the fourth will be natural treatments that can help to alleviate some of the symptoms in a pharmaceutical manner, such as lowering stomach acid.

5:21 When we come back to the first level we first have to look at food allergies or sensitivities. This may be approached with a paleo or autoimmune paleo diet or an elimination diet and the foods typically eliminated are wheat, dairy, caffeine, night shades, spicy foods, alcohol, and night shades are some of the most common ones. Food sensitivities can provocate reflux and this is why histamine blocking agents, which are often recommended to treat GERD, may be working by blocking the effects these food sensitivities. Elevated histamine levels can raise hydrochloric acid levels in the stomach and this is why histamine blocking agents can lower stomach acid levels.   Dr. Ruscio talked about following either a paleo diet, an autoimmune paleo diet, or an elimination diet and then slowly reintroducing the foods you have eliminated and see what foods work for you and which foods don’t work for you.  There are also other dietary approaches that may work including a low FODMAP diet, which eliminates foods that may cause gas and bloating, which may push up against that lower esophageal sphincter and keep it open. At least one systematic review shows that IBS and GERD have quite a bit of overlap.

10:15  I commented that I know that Dr. Ruscio tries to avoid necessary testing, but I have sometimes found it helpful to do food sensitivity testing to find out which foods, esp. if they are not the obvious foods like gluten, dairy, and soy. Dr. Ruscio explained that he’s not against testing but he tries to use testing judiciously in order to avoid having his patients spend more money than necessary and he’s been able to sort out most cases of GERD and IBS without needing to do food sensitivity testing. Dr. Ruscio also mentioned that a low histamine diet should be considered after other dietary approaches have failed. He pointed out that there is not complete agreement about which foods should be excluded on a low histamine diet,

13:06  I said that Dr. Ruscio mentioned that reflux is associated with high stomach acid but many Functional Medicine doctors believe that reflux may be associated with low stomach acid, resulting in poor digestion/breakdown of the food.  I mentioned Dr. Jonathan Wright’s famous study that looked at patients who were believed to have elevated stomach acid but who actually had lower hydrochloric acid levels.  Dr. Ruscio explained that he fact checked Jonathan Wright’s references from his book and none of his references stood up. Dr. Ruscio pointed out that he has a lot of respect for Dr. Wright but his references were miss-cited and some of the references he cited actually showed the opposite of his position, which is that in studies looking at lower esophageal sphincter tone that gave patients acid lowering medications, they showed a tightening or an improved function of that sphincter.  But while this mechanism for reflux that Dr. Wright cited is not accurate. there may still be some efficacy in prescribing Betaine HCl, which facilitates stomach healing.  Dr. Ruscio pointed out that in the Functional/Natural Medicine community there is an overuse of hydrochloric acid supplements and this can become problematic, esp. for patients who have gastritis, and taking acid can make gastritis worse.  And some of these doctors cannot even conceive of the fact that giving this acid is not the right thing to do. 

17:04  I mentioned that a lot of these practitioners are using this regimen of increasing the HCL tablets, adding an additional tablet per day till the patient feels a burning in their stomach and then back off the dosage. Dr. Ruscio said that he also would recommend against this strategy, but he wanted to get back to his hierarchy and talk about the second level of the pyramid. This level would be dysbiosis. For practitioners who are treating patients with GERD who do not have resolution after diet, would be to look at dysbiosis and two of the most salient forms of dysbiosis would be Small Intestinal Bacterial Overgrowth and H. Pylori infection. He explained that he does not consider H. Pylori to be a pathogen because there is not universal data showing that H. Pylori is actually detrimental. Some data shows that early colonization with H. Pylori may actually be protective of the host, at least immunologically. Also, it does not appear that we can fully eradicate H. Pylori. It’s more a matter of creating a balance by trimming the levels back. But H. Pylori has been documented to cause stomach ulcers and it may cause an increase in HCL levels.

19:42  I interrupted and asked what is the best way to test for H. Pylori?  Dr. Ruscio said that if it is highly suspected, such as in a patient with GERD or a history of ulcers, he will run a stool antigen profile, a breath sample, and a blood antibody profile. With respect to SIBO, the connection is that SIBO is one of the causes of IBS and IBS is connected with GERD. Part of this may be because SIBO can cause increased gas pressure, which can push on the esophageal sphincter, esp. if SIBO occurs high up int he small intestine, closer to the stomach.  Or histamine may be the connection since a low FODMAP diet, which has been shown to help with SIBO, has been shown to cause an 8 fold decrease in histamine levels.  Between SIBO and H. Pylori you can get a lot of mileage with treating GERD. 

22:19  Then we come to the issue of stomach acid and this would include stomach acid being too high or too low.  If patients have high stomach acid, then their risk of gastritis or ulcers or GERD is increased.  Some of the symptoms of indigestion can also be caused by low stomach acid.  The symptoms of low and high stomach acid have a lot of overlap.  There are a few things you can do to try to sort this out and determine which way to go clinically.  The things that would make you more at risk of having higher stomach acid are younger age, a gnawing type of stomach pain, if someone reports a negative reaction to taking supplemental stomach acid, and a personal or family history of ulcers or gastritis.  Patients who are older or have anemia or autoimmune diseases are at higher risk of having low stomach acid and these patients would be good candidates for a trial of betaine hydrochloric acid.  Dr. Ruscio explained that he tells these patients that they will feel better or worse and if they feel worse than this is likely because they have gastritis or an ulcer. And this is sometimes missed and he has seen some patients who had seen other providers who were taking acid and it was making them worse. To put some numbers on this, the number of documented ulcers in the US is 6.5%, while the number of low stomach acid is 2%, though he admitted that we have more research on ulcers than we have on low stomach acid.  On the other hand, we see up to 30-40% low stomach acid in those with autoimmunity. Dr. Ruscio emphasized that the biggest take away is that not everyone will benefit from taking acid and sometimes the key to solving the case is to go the opposite direction.  He talked about a case of a patient who he helped relieve a lot of his symptoms, including gas, bloating, insomnia, and fatigue with treatment of small intestinal bacterial overgrowth. But he continued to have this gnawing stomach pain, anxiety, and he would get goosebumps and he thought that this was gastritis related, so he put this patient on a protocol to lower stomach acid, and that was the final missing piece that allowed him to heal.  Also, we need to recognize that blocking acid may have some benefits and patients who have ulcers who go on an acid blocking medication 80-90% will heal by using acid lowering medications for 4-8 weeks and natural agents can be as effective as prescription medications. Dr. Ruscio mentioned one study that showed that natural agents could be as effective as taking omeprazole, the leading pharmaceutical agent (Prilosec). 

27:57 I asked Dr. Ruscio what his favorite natural acid lowering medications are? Dr. Ruscio said that melatonin can be helpful. He mentioned a study that used melatonin, B vitamins, methionine, and betaine. He said that there are two formulas that approximate that. One is Protexit (not sure of spelling) and the other is GI Guard PM from Protocol For Life Balance.

29:12 I asked that since SIBO is often associated with decreased small intestinal motility, and some evidence indicates that decreased esophageal motility may be a causative factor in reflux. Could it be that the decreased motility part of the SIBO be affecting the motility of the esophagus and could this be why treating the SIBO helps with reflux?  Dr. Ruscio said that he thought that this could be the case and this is one reason why SIBO may be associated with reflux. Certain pro-kinetic changes, like Iberogast, a natural prokinetic, in several clinical trials has been shown to be helpful with dyspepsia or indigestion, which often times includes GERD or symptoms of GERD.  Iberogast was used in one head to head trial against Cisapride, which is a pharmaceutical upper GI pro-kinetic. The Interstitial Cells of Cajal (ICC) run all the way through the entire GI tract. Dr. Ruscio summarized by saying that that gives you a pretty good rundown by starting with diet, then looking at dysbiosis, and if someone is still non-responsive, considering direct acid modulation. There are one or two other things one may want to add in, such as something that facilitates healing in the gastrointestinal tract, gut healing formulas that contain things like aloe, glutamine, zinc, slippery elm. Dr. Ruscio said he likes to use GI Revive but there are many similar formulas. For GERD and indigestion there’s a compound known as FDGard, which can help with dyspepsia or indigestion. It contains peppermint oil and caraway oil. I mentioned that I just read an article by Dr. Hyman who said that magnesium deficiency can be a problem since you need magnesium for the sphincter at the bottom of the stomach to relax to facilitate the movement of the food. Dr. Ruscio also said that if you have a bad case of gastritis or an ulcer, don’t be afraid to use an acid lowering medication for a limited period of time.  If you have SIBO and an ulcer, then you will be better off treating both the SIBO with herbs and also treating the ulcer with a PPI.  The real miss is when using such medications for the long term. But if you address these other foundational factors, then the need to use these in the long term is non-existent.  And patients appreciate you as their practitioner being open to both natural and conventional medicine.

Dr. Michael Ruscio can be reached through his website, https://drruscio.com/  where you can sign up for his newsletter, to see his weekly videos, his weekly podcast, blogs, and for his practitioner training program, the monthly Future of Functional Medicine Review clinical newsletter, which I highly recommend. He is also available for Functional Medicine consultations as well as for speaking events.

Dr. Ben Weitz is also available for nutritional consultations at 310-395-3111

 

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