The IBS and GERD connection

The Cometa Wellness Center

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are very common disorders in the general population. Symptoms of IBS are commonly encountered in GERD patients, and symptoms of GERD are not uncommon in IBS patients. "GERD and IBS may be two distinct manifestations of a similar underlying pathophysiologic process that can affect different levels of the gastrointestinal tract. ...the reason for the overlap observed between GERD and IBS remains to be elucidated..." I quote these words because I read them over and over again in the medical literature. The "overlap" observed between disease states in the human body will always be illusive in the medical paradigm where the body is broken down into parts! The specialization of medicine has made it very difficult for a person to be viewed by the doctor as a WHOLE person.  I quote the old adage...

                                        'View the forest not the trees'

The most important thing to remember when it comes to your digestion is that it is responsible for digesting your food! Gut mucosal integrity is essential for both competent digestion and the correct absorption of nutrients. Factors such as digestive enzymes, mucus, bacterial flora, and low pH (yes! an acidic environment!), are integral to mucosal integrity, health and function. Proton-pump inhibitors (i.e. the stomach acid-inhibitors such as Nexium, etc), NSAIDs (e.g. Motrin), steroids, antibiotics and poor dietary habits are examples of culprits that breakdown the first line defense against hypersensitivity to food proteins, as well as the aid we need in digestion and nutrient absorption.

What the current medical literature DOES NOT tell us about GERD

For those whom suffer from GERD, you should know there are no studies to document that GERD is an 'excess acid production' problem. The acid is simply stagnant with the food in your stomach (i.e. a delayed gastric emptying rate) and moving up into the esophagus rather than down from the stomach into the small intestine in a timely fashion. This is due to a breakdown in the functional gut mucosal integrity cited above. The fundamental abnormality in gastroesophageal reflux disease is exposure of the esophagus to acidic gastric contents, resulting in injury and/or symptoms.

As we understand GERD, there are now 2 known types of this disease. The most well established type is erosive esophagitis, (EE) where there is inflammation and the potential for Barrett's esophagus (i.e. esophageal cancer potential). This disease is correlated with regurgitant esophageal acid exposure, NOT excessive stomach acid production! There is also a second type of GERD, known as non-erosive reflux disease (NERD). This version of GERD is actually more predominant and accounts for over 50% of gastroesophageal reflux. Patients with NERD have typical reflux symptoms caused by the esophageal reflux of gastric contents but have no visible esophageal mucosal injury. This is in contrast to patients with erosive esophagitis and Barrett's esophagus, who have obvious esophageal mucosal injury on endoscopy.

IBS and GERD

It is the more common nonerosive gastroesophageal reflux disease (NERD), which frequently has features of irritable bowel syndrome (IBS). Irritable bowel symptoms are hence often associated with reflux symptoms, but not necessarily with acid exposure. Recent studies have demonstrated that GERD patients who also suffer from IBS-like symptoms perceive their GERD-related symptoms as more severe and are less likely to respond to anti-reflux treatment, as compared with those without IBS. The presence of both IBS and GERD in a patient is considered a likely explanation for "the failure" of proton pump inhibitors to treat GERD.

Although acid reflux gives rise to similar symptoms in both NERD and EE patients, the underlying mechanism of acid injury may be different. A breakdown in the mucosal integrity of the esophagus predominates in NERD and resembles the gut permeability disorder we reviewed in the June 23, 2010 blog, "Treat IBS Naturally and Effectively". Remember from this review that there are tight junctions between the cells that line the gut mucosa. These tightly adhered cells form the primary barrier between the external environment (e.g. our food) and the internal environment of our body. We now know from clinical research that "dilated intercellular spaces may be responsible for the enhanced perception of proximal acid reflux and that these dilated intercellular spaces are a feature of NERD patients, irrespective of esophageal acid exposure". These mucosal changes are considered an objective, structural marker of reflux symptoms. Through the food allergy response described under Food Intolerance in the June 23, 2010 blog, the food intolerant person slowly looses the tightly regulated mucosal immune response that protects them from untoward micro-inflammation. This leads to structural changes in gut mucosal integrity. This sounds an awful lot like the "dilated intercellular spaces" described in the medical literature that are now considered a structural marker of reflux, but NOT always related to esophageal acid exposure. The presence of IBS features in a large proportion of NERD patients reflects a high prevalence of visceral (i.e. gut) hypersensitivity that may aggravate acid reflux symptoms. Do you think there is a connection between food sensitivity/allergy, IBS and GERD pathophysiology? Of course!

Those nasty Proton-Pump Inhibitors!

GERD patients with a poor response to acid suppression treatment are seen a lot. Even double proton pump inhibitor dosing does not relieve symptoms in many patients with GERD. The literature clearly states that current definitions of acid reflux require review and the precise role of acid in NERD (type 2 GERD) needs further clarification.

Yes, proton-pump inhibitors may wipe out GERD symptoms, by taking away the acid production naturally found in the stomach. Yes, they also reduce esophageal exposure to acid and consequently reduce the incidence of Barrett's esophagus. But, would it not be better to keep Mother Nature's plan, and allow the acid to reside in the stomach? Would it not make more sense to help the acid do its job in a timely fashion, by facilitating digestion and the normal propulsive forward motion of food through the digestive tract? Let's look at what we do when we inhibit stomach acid production. By inhibiting acid production, we are:

• 1. Inhibiting the first line defense our body has to kill pathologic bacteria that has entered the stomach from the mouth.
• 2. Inhibiting the production of enzymes that are low-pH (acid) dependent in the stomach and small intestine.
• 3. Inhibiting the essential breakdown of food in the stomach before it continues into the small intestine.
• 4. Likely reducing the ability of the lower esophageal sphincter (thought to be acid sensitive for its closure) to close and hence increasing reflux!

Note, that by taking Nexium-like drugs, one is not only is often UNABLE to address NERD, BUT is also breaking down the first line defense to disease in the gut! Does any of this sound like a good idea? NO!

Natural Approach towards GERD for disease cure, not symptom suppression!

Integral to most of the GI support programs I have successfully implemented in my medical practice, is the recognition and treatment of food intolerance. The loss of food tolerance leads to hypersensitivity. Such food hypersensitivity can lead to an array of gastrointestinal disorders. The many causes of food intolerance are still a quandary to conventional medicine. This is not the case for those of us that implement natural medicine. One very common type of food intolerance is food allergy and/or sensitivity. Whether it be GERD, IBS, Colitis, Gastritis, Peptic Ulcer Disease (PUD), or any combination of the above, the identification of food allergy in that patient is imperative. Food allergy and sensitivity testing is available at The Cometa Wellness Center. One does not need to be a patient with Dr. Cometa to take advantage of this very useful testing available at the Center. Call the Center at 410-296-6100 if you would like to be tested.
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Stay tuned to The Cometa Wellness Center blog with drcometablog.com to learn how correct nutritional and herbal support can enhance your Gut Integrity and Digestion/Nutrient Absorption.

Ariane Cometa MD, the holistic doc
The Cometa Wellness Center Pharmacy