Upper Digestive Issues: Gastritis, Ulcers and GERD

Welcome to The Perfect Stool. This is your host, Lindsey Parsons, and today I'm going to be talking about acid reflux, low stomach acid, ulcers, and gastritis. And I realized I should probably be making a disclaimer on all of these podcasts that they aren't intended to diagnose or treat disease but are for educational purposes only. So there it is. So the problems I'm talking about today happen north of the intestines, in the stomach, or in the first part of the small intestine called the duodenum. And 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 other problems in your gut, like a microbial imbalance or because their origins are bacterial gut infections that traditional doctors don't know how to look for or treat. So let's start with gastritis. This is a first-line problem where your stomach is bothering you, and it can be asymptomatic or can have symptoms such as indigestion, nausea, or recurrent stomach upset, bloating, pain, vomiting, including vomiting of blood or material that looks like coffee grounds, a burning or gnawing feeling in the stomach between meals or at night, hiccups, a low appetite, or black tarry stools, which are indicative of blood in your stool. And all of this means that you have inflammation, irritation, and/or erosion of the lining of the stomach. So you can have an acute or sudden case of gastritis, or it can come on gradually and last a while, which would be considered a chronic case. But either way, if you catch it early, gastritis can be dealt with pretty easily But left untreated, it can lead to a severe loss of blood and may increase your risk of stomach cancer. So you don't want to ignore it. Now, 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 end up seeing a doctor who may do an upper endoscopy, which is when they put the, the camera down your throat and look at your esophagus and stomach. 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 and which can give you some of the same symptoms as gastritis, which I'll talk a bit more about later. 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's on the ball, he or she will also check for H. pylori or Helicobacter pylori, which is a bacteria that can cause these symptoms. And again, I'll touch a lot 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 the problem was H. pylori all along. So many of the causes of gastritis are within your control, like if you're using alcohol excessively, you can stop it or reduce your use. If you have an eating disorder, chronic vomiting can also cause gastritis, so you may need to get professional help with that. And of course, our old friend stress may also cause gastritis. So either eliminating your sources of stress or mitigating them may help. And if you're taking NSAIDs, or nonsteroidal anti-inflammatory drugs, including acetylsalicylic acid, which is a drug in medicines like aspirin, ibuprofen, which is in Advil and Motrin, diclofenac, which is a topical pain cream found in a product called Voltaren, and or naproxen sodium found in Aleve, that's another way to end up with gastritis. So if you can stop or reduce your use of those drugs, that may help. You can take acetaminophen without these negative side effects to your stomach, although I am well aware that doesn't take care of the exact same problems as some of those other medications. And then the last possible causes of a 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. So if you are diagnosed with gastritis, one treatment that you're likely to be offered by your doctors is to either take antacids or other drugs such as proton pump inhibitors, also known as PPIs, or H2 blockers to reduce your stomach acid. Some examples of those are Nexium, Protonix, Aciphex, omeprazole, Prilosec, and Prevacid. And those are all sold over the counter, which makes them seem innocent. But let me warn you, as someone who took them continuously for 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, mal digestion 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 of those things that wasn't definitely diagnosed for me was mal digestion of protein, but I had all the rest. So if you have to take a PPI, my recommendation is to follow the instructions on the package that says not to take it for more than 14 days. And if your problem doesn't resolve in 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. So I thought I was only lactose intolerant, and I would take my lactose pills dutifully every time I ate dairy. But it turns out I was also intolerant to casein, which is the protein in dairy. And when I completely cut out dairy, my 15 years of acid reflux disappeared. And I had previously cut out gluten. It was a sad day, but as my French friend had 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?" And those words rolled around my head for about a year before I was willing to face the loss of my beloved dairy. But I haven't looked back. I've learned to replace that creamy, salty, umami flavor of dairy with avocado or just make different dishes that don't require dairy. And I do occasionally cheat and take my pills to digest gluten and dairy if I'm having Neapolitan pizza or burrata cheese, but that's about it. So back to treatments that your doctor may recommend for gastritis. This could include recommending you avoid hot and spicy foods, eliminating gluten or dairy, which are two of the most likely dietary culprits. Or if your issue, issue is 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. I'll talk a little bit more later about the best way to deal with H. pylori as I discuss ulcers. Some more functional medicine type treatments for gastritis will include taking DGL or deglycerinated 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 the probiotic Culturelle, which you can find at mainstream pharmacies. You can also find it through other manufacturers. That 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, 'cause it can get worse. So let's talk about ulcers next. So if you, if your gastritis is left unchecked, depending on its root cause, it can turn into an ulcer, which is an open sore on the inside of your stomach. Also known as 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. And the main causes of these, like 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 anxi— anxiety or depression, or the drugs Fosamax or Actonel. And some symptoms of ulcers include burning stomach pain, feeling of fullness, bloating, or belching, intolerance to fatty foods, heartburn, nausea. And some more severe but less common symptoms include the vomiting or vomiting blood, which may be red or black looking, dark blood in your stools or stools that are black and tarry, trouble breathing, feeling faint, unexplained weight loss, and appetite changes. And so 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've since learned isn't exactly true. So Drs. Barry J. Marshall and J. Robin Warren, Australian researchers, discovered in 1982 that H. pylori was in fact the root cause of what we now know to be more than 90% of duodenal ulcers and up to 80% of gastric ulcers, for which they were awarded a Nobel Prize 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 the prolonged use of NSAIDs like ibuprofen. And 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 by the way is what my doctor prescribed as the maximum safe dose without any warning about ulcers, although of course I knew better. And so what happened was first I started feeling an acidy feeling in my chest, like it felt like it was burning or just a slight discomfort in a particular place in my stomach after taking ibuprofen. But I was so desperate for pain relief that honestly I kept taking the ibuprofen for like 7 to 10 days after this sensation started. But it kept getting worse and eventually I knew I had to stop or I'd end up with a bleeding ulcer. So I've had since had to switch to acetaminophen, and even though it's not as good for my type of pain, I really had no choice. So now I just reserve that ibuprofen only for my worst days. And the good news is that I was able to resolve my 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 did resolve quickly. The bad news is I'm on another drug now to help relax my muscle spasms called tizanidine, which is starting to cause an acidy stomach. So I may have to dip back into the PPIs or stop the tizanidine. So I've got a bit of dilemma, as I imagine many of you have faced when you've been 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 now I can totally appreciate as I try to control my pain while trying to resolve the root cause of my sciatica. But getting back to our old friend H. pylori, which is the primary cause of ulcers, the dilemma with H. pylori 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 to 50% have it in developed countries. But only 10 to 15% of people who have H. pylori will develop peptic ulcers. And then there's also some strains of H. pylori that can cause gastric cancer, but not all. So if you have it, it's important to find out not just if you have it, but which strain you have and if it's problematic one, which you can do so using 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, 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 it also tests for other known gut pathogens as well as signs of gut dysfunction originating in your digestive organs. So the way that H. pylori causes peptic ulcers is by attaching itself to the protective mucus coating of the stomach and duodenum and weakening it, and then that allows acid to reach the sensitive lining beneath it, causing an ulcer to form. So if you leave that untreated, you can have stomach perforation and bleeding. But ironically, some studies show that H. pylori can actually be protective against gastroesophageal reflux, aka GERD, or acid reflux, and esophageal carcinoma. And the former, or the prevention of GERD, is documented in fascinating detail in Martin Blaser's book, Missing Microbes, which made me wanna go out and get H. pylori because of the GERD that plagued me for years. And Dr. Blaser, what he did, he had H. pylori but wasn't having any symptoms. He was asymptomatic and he cleared it out with antibiotics and then he found that he had GERD after that. So he reinoculated himself with H. pylori and it turns out that there are certain strains of H. pylori, the CAG A+, or A-positive ones that can reduce the acidity of the stomach, thereby raising its pH, which can prevent GERD and Barrett's esophagus and adenocarcinoma, which is a kind of cancer of the esophagus. However, what I've seen with clients with H. pylori, usually they're having problems, and it's a— there's a sequence of events that leads to problems. So first, you'll 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, also known as HCl. So HCl promotes the release of bile, which helps metabolize fat in the small intestine. So you can end up with fat maldigestion, which can lead to nutrient deficiencies. So if your stool is pale or floating, that may be because you don't have enough bile production, whose origins are starting with the low stomach acid or the H. pylori. So then as a result of the low stomach acid, you can also get a rise in pathogenic bacteria or overgrowth of commensal or beneficial bacteria that are not killed off in your acidic stomach, such as Escherichia, including certain pathogenic strains of E. coli, Clostridia, including Clostridia difficile or C. difficile, which we often see people getting after hospital stays and which causes explosive and frequent diarrhea, Enterococcus, including Enterococcus fecalis and fecum, Streptococcus, and overgrowth 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. So long, long story short, low stomach acid is not good to have because it messes up everything. So eventually what may happen is you'll actually have an increase in stomach acid, which will cause similar symptoms of acid reflux, bloating, gas. But I do wanna stop for a minute to make 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 with GERD, and prescribe PPIs. So the normal pH of a stomach for healthy protein digestion is between 1.5 and 2.2, and the proper pH is a trigger for the contraction of the lower esophageal sphincter, which is just above the stomach and which protects your esophagus, that delicate soft tissue, from the harsh acids, which are, which are in your stomach. And if your stomach acid is too low, that sphincter remains open, letting acid up into your esophagus, which will cause the GERD symptoms like that burning or an incessant cough, which prompts people to take antacids or PPIs. So these medications then exacerbate the problem by preventing the proper digestion of foods, especially proteins, which you need HCl to digest, and stressing the enzymatic system of your pancreas and other digestive organs. Because they're prompted to secrete enzymes in response to your stomach acid levels. So this then can lead to calcium deficiencies, iron deficiencies, B12 deficiency, vitamin A deficiency, which then leads to increased inflammation and gut damage and protein deficiency, all of which lead to other problems in the body. So when you have a low stomach acid situation brought on by H. pylori or other reasons like aging, you'll often 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 gallstone and a vegetarian or vegan diet. But now back to the question of whether stress is a potential cause of ulcers, because the reality is that probably is, but indirectly. So while H. pylori may be the 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 I think this follows. First, when you're in chronic stress, you have a decrease in something called secretory immunoglobulin A, or SIGA, which is the first line of antibody defense in your mucous membranes that would deal with pathogens. And so that will decrease in response to chronic stress. As a result, when your gut defense systems are down, you can have that overgrowth of H. pylori. Which can then lead to an ulcer or a decreased stomach acid or other, other gross, as I mentioned before. So as I mentioned, there's a better way to deal with H. pylori than by taking tons of antibiotics and completely messing with the balance in your gut microbiome. And that's to take Masticagum, which is quite effective in treating H. pylori along with probiotics of various types, DGL, and slippery elm, which will help coat your stomach. And if you can tolerate it and appears that you have low stomach acid, you can supplement with betaine HCl using the betaine HCl challenge approach, which I'll describe in a minute. But before I get there, I wanted to just finish up on the topic of GERD, or gastroesophageal reflux, which again is when the lower esophageal sphincter lets acid up into the esophagus from the stomach. So we already touched on some possible causes, including low stomach acid and H. pylori., but other possible causes are a hiatal hernia, pregnancy, scleroderma, which is not 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 try to figure out what the root cause of your excess stomach acid is and address it., but normally we actually have less and less stomach acid as we age. Now, if you have no other possible root causes, as I mentioned, you're negative for H. pylori, you can start by trying the betaine HCl challenge to see if you have low stomach acid and this is causing your GERD. So the way you do that is by starting with 1 capsule per meal, um, only meals including animal protein. So the capsules of betaine HCl are typically sold in the 500 to 750 milligram range. Um, if you have a lower dosage, it makes fine-tuning your dosage a little easier. And then you can increase your dosage by 1 capsule per meal every 2 days. So each meal with protein for 2 days, you'll take 1 capsule. Provided that you feel good with that, then you'll move up to 2 capsules. And you're gonna keep going up to as many as like 5 capsules until you feel a heartburn or warmth in your stomach. And then you'll back down to your previous dose. And it may be that over time you'll be able to back down as your stomach starts to produce more acid. But if you immediately feel a burning, or when you do feel a burning, it may be that you have excess stomach acid, or maybe 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. Now, there are some contraindications for using betaine HCl, which include Barrett's esophagus, a 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 regularly or have a diagnosed blood clotting disorder. But an alternative to taking betaine HCl is to have 1 to 2 tablespoons of apple cider vinegar or lemon juice mixed in water 10 to 15 minutes before meals. But again, if you have a diagnosis of Barrett's esophagus, esophageal strictures, or reflux esophagitis, you shouldn't use those 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. And I'll link to good options for both the betaine and the digestive enzymes in the show notes. Whew. So that was a lot to absorb, so I better stop there. If you have any follow-up questions, a great place to ask them is in my Facebook group called Gut Healing. And if you're struggling with these issues or other gut health issues and need some help, that's what I do for my clients. So I offer a free 1-hour breakthrough session to talk about your issues and to see if gut health coaching might help you resolve them. You can set that up by going to the link in the show notes. And if you'd like to support the show, you can make a regular donation on Patreon or buy vetted, high-quality supplements from my FullScript or Roll of Eight dispensaries, or give me a 5-star review on Apple Podcasts. So that's it. Thanks for listening, and here's wishing you all the perfect stool.