My Stomach’s on Fire and I Can’t Put It Out
Most of us call this
common complaint indigestion, but doctors call it dyspepsia.
Indigestion is an old English word that means, “lack of adequate
digestion.” Dyspepsia means impaired gastric or digestive function. But
what we are trying to communicate is “suffering from discomfort, burning,
or pain in our upper central abdominal area.” We explain our feelings by
saying we have an upset stomach, heartburn, acid indigestion, and acid
Fifty-six per cent of the people in Western countries report they have
suffered from heartburn at some time in the past and 36% have symptoms at
least once every 4-6 months.1 Half to two-thirds of pregnant
women suffer heartburn during pregnancy. Patients with indigestion and
acid reflux report worse emotional well-being than do people with heart
failure, symptomatic heart disease, diabetes and hypertension.2,3
My guess, based on people I have seen, is that this problem is even
more common than reported. Walk down the medication aisles of your local
supermarket or drug store and you’ll see shelves of liquids and tablets
intended to neutralize the acid, and pills to prevent acid production.
Most people rely on self-medication to treat their discomfort, but the
prescription side of this heartburn business is huge. The first and third
largest sum of money spent on any prescription medication in the year 2000
was for two antacids, Prilosec and Prevacid.4 This amounted to
nearly $7 billion spent in the United States for that year – just for just
GERD is the (Key) Word
The source of almost half the indigestion suffered is from the retrograde
flow of the stomach contents up into the esophagus – a condition called
gastro-esophageal reflux disease or GERD. This condition is
often felt as a burning feeling behind the sternum (breastbone) that
radiates up toward the throat and is worsened by a meal or by lying down.
The primary cause of the symptoms and associated tissue injury is the
presence of stomach acid and other digestive juices outside of the
stomach. GERD occurs in 7% of people daily and 36% of people at least once
a month.5 The diagnosis is usually made by the doctor
listening to the patient’s symptoms. Further evaluation of the disease is
most commonly done by looking at the esophagus through a tube known as an
endoscope. However, no evidence of disease is found by this examination
in a high percentage of people with symptoms of GERD.
Acid Can Burn Your Mouth, Throat and Lungs
Complications from acid reflux, GERD, can be as minor as heartburn or as
severe as deep ulcers and cancer. When the acid refluxes into the mouth
and is inhaled into the lungs, serious disease, like erosion of the teeth
and asthma, can result.
Erosion of the Teeth
Erosion of the enamel of the teeth is caused by the reflux of stomach acid
contents into the mouth. The acid destroys the tooth enamel and the loss
is permanent. This condition is commonly seen with a weight control
method known as bulimia, which is used by 4% to 10% of college age women.
Dental erosion is seen in 69% of patients with bulimia, due to acid on the
teeth from repeated vomiting. When people without bulimia, but with
dental erosions, were studied it was found that 83% had evidence of GERD.6
This relationship was confirmed when 40% to 70% of people with GERD were
found to have erosions.6 The worse the reflux the more likely
the finding of erosions.
Damage to the oral-sinus cavities from GERD:
Loss of taste
Ear pain and
Asthma and Upper Airway Problems
Acid refluxed up into the back of the throat can be inhaled into the
bronchial (airway) tubes and burn them, causing constriction, swelling,
and large amounts of mucus production. Somewhere between 34% and 89% of
asthmatics have GERD.7 Seventy-five percent of children with
asthma have GERD.7 Patients with asthma caused by GERD commonly
complain of heartburn, regurgitation, and difficulty swallowing. Their
asthma is worsened by meals and when lying down, or sleeping. Treatment
with a healthy diet that reduces the chances of reflux, raising the head
of the bed by four to six inches, and as a last resort, antacids, will
relieve asthma and many other breathing problems, and reduce the need for
Airway problems from GERD:
Inflammation of throat
Vocal cord ulcers
Noncardiac chest pain
The Causes of Indigestion and GERD
Gastroesophageal reflux disease (GERD) occurs when the stomach acid
contacts the tissues of the esophagus, mouth, sinuses, and lungs. For
this to occur, acid must reflux past the “natural anti-reflux barrier”
between the esophagus and the stomach. At rest, the most important
component of this barrier is the lower esophageal sphincter (LES).
The LES is an area of increased muscular activity, which produces
pressures which keep the opening between the esophagus and stomach closed
most of the time when we are not swallowing. However, when this LES
relaxes at inappropriate times, acid can reflux out of the stomach causing
GERD. There are two general reasons the LES functions poorly. The first
is due to actual structural damage of the LES caused by years of an
unhealthy diet with resulting constipation and failing to squat when
defecating. Second, many of the foods and beverages we consume cause this
sphincter to transiently relax permitting the reflux of acid.
A Low Fiber Diet Permanently Damages the Anti-reflux Barrier
At least one well respected researcher of gastrointestinal diseases
believes that more than 90 percent of the GERD found among people living
in the Western world is a direct result of constipation.9
Physical efforts to evacuate a hard, constipated stool out of the rectum
into the toilet cause severe straining that pushes the stomach from its
normal position in the abdominal cavity, up into the chest. (For a
moment, picture a red-faced person sitting on the toilet seat grunting and
groaning in an effort to pass his tiny rock-hard stool). As a result of
all that physical effort, the natural opening in the muscular diaphragm
through which the esophagus passes is widened, creating a hiatal hernia.
Eventually, part of the stomach lies in the chest cavity, then with each
breath negative pressures are created that pull acid up into the
esophagus. The strength of the LES is also gradually weakened over time
as a result of chronic straining to defecate.
Constipation is caused by a diet low in dietary fiber and by dairy
products.10,11 Dietary fiber is only present in plant foods –
naturally, the meat and dairy-based, highly refined American diet is very
low in fiber and constipating. The American diet contains about six to
ten grams of fiber daily, whereas a healthy diet based on starches,
vegetables and fruits has 40 to 100 grams of dietary fiber. Dairy
products can paralyze bowel activity resulting in constipation, and the
protein is the cause – so low-fat dairy will be at least as harmful.
Another source of damage to the LES and a cause of hiatal hernia is from
abandoning the historically common and worldwide practice of squatting to
defecate.9 Less force is required to evacuate the stool when
in a squatted position over a hole in the ground rather than when on a
Another chronic dietary disease associated with indigestion and GERD is
obesity.12 This association most likely reflects poor health,
the presence of a hiatal hernia, and damage to the LES than any direct
effect of extra body fat pushing on the stomach. However, excess body
fat pushing on the stomach and tight clothing have been suspected of
increasing acid reflux.
Short-Term Dietary Causes of (Transient) LES Dysfunction
Fat, chocolate, peppermint, onions, coffee, decaffeinated coffee and
overdistention of the stomach are all believed to cause heartburn by
decreasing the pressure of the lower esophageal sphincter and increasing
the number of relaxations of this sphincter.14-27
Thirty years ago a high fat diet was recognized as a cause of acidity,
heartburn and belching, and one doctor reported that a diet with no added
fat cured 425 of 532 patients found to be fat-intolerant over a three year
period of observation.13 Recent studies at the University of
Virginia Health Sciences Center confirmed that fat causes heartburn.14
In 12 healthy volunteers and 11 patients with reflux esophagitis, saline
or fat was infused into the duodenum (the first part of the small
intestine). Fat directly aggravated reflux by increasing the number of LES
relaxations. Other research has found the reflux of acid becomes
progressively worse over the next three hours after eating a meal high in
The same group of researchers from the University of Virginia Health
Sciences Center found that over-distention of the stomach caused
indigestion.16 By inflating balloons which had been inserted
in peoples’ stomachs the researchers produced an increase in the rate of
LES relaxations. Their overall conclusion was that large fatty meals
which distend the stomach are a major cause of heartburn. The pains were
found to be even more frequent in people who drank a lot of coffee after
meals and with smokers.
Onions, chocolate, and mints:
Onions, chocolate, and mints have all been shown to cause indigestion
by relaxing the LES.17-21, The effects of onion on acid reflux
and reflux symptoms were investigated in 16 normal subjects and 16
heartburn subjects.17 Subjects were studied by testing the
acid in their esophagus two hours after the ingestion of a plain hamburger
and a glass of ice water. The identical meal, with the addition of a slice
of onion, was ingested on another day. Onions significantly increased all
measures of heartburn in subjects and were found to be a potent and
long-lasting cause of reflux in heartburn patients. Cooking onions
destroys substances that are the cause of indigestion. This is why most
people have no problems with cooked onions.
Chocolate syrup (even low-fat syrup) produces immediate and sustained
decreases in LES pressure and symptomatic reflux in people.19
Approximately 40% of people surveyed had symptoms of heartburn after
chocolate.5 However, in the same survey 76% of people said
fatty foods caused their symptoms. Dark chocolate with its high fat
content (50% fat), may therefore cause an even greater fall in LES
pressure and more heartburn than low-fat chocolate.
Regular and Decaffeinated Coffee:
Coffee is upsetting to the stomach because it causes relaxation of the
LES. Decaffeinated coffee also causes indigestion by reducing the LES
function, but the effects are somewhat less.22-24 Caffeine,
however, does not cause LES dysfunction. Another interesting finding is
that regular ground coffee and decaffeinated coffee stimulate acid
secretion by similar amounts. 25 This means substances in the
coffee other than caffeine are causing the heartburn and reflux. More
recent studies suggest that LES dysfunction and gastroesophageal reflux,
rather than acid production, are responsible for the heartburn caused by
coffee.26 Therefore, for relief, coffee drinkers must
switch beverages to something like herbal tea or water, rather than
Even though there is considerably more indigestion among coffee drinkers,
there is no increase in the risk of stomach or duodenal ulcers.27
Smoking Cigarettes and Alcohol:
Cigarette smoking and alcohol will lower LES and cause indigestion.28-30
However, most of the distress from alcoholic beverages comes from
irritation of the stomach linings and the production of acids. Next month
we will discuss important ways some alcoholic beverages, like wine and
beer, cause stomach distress.
Citrus Fruits, Spices, and Tomatoes Are Irritating
Think about your reaction to drinking grapefruit juice or orange
juice. Immediately my thoughts are of a sour stomach and burning
indigestion. Citrus fruits, tomatoes, and spicy foods cause most of their
distress by a direct irritating effect on the tissues of the esophagus and
stomach, since they do not appear to lower LES pressure.31
Acidity is thought not to be the cause of the heartburn since
neutralized orange juice also produces heartburn.21 The
heartburn effects of fruit juice must result from the disruption of the
fibers and other protective substances in the fruit caused when making the
juice, because the whole fruit rarely causes distress in people.
I have also found raw vegetables more irritating than cooked. Some of the
most troublesome are onions, green peppers, cucumbers and radishes.
Three meals chosen specifically to cause heartburn:
Investigators looking into the causes of heartburn have tried to find
the meals that will reliably produce severe distress.32 They
chose the following meals:
A McDonald’s Quarter Pounder, a small
order of fries, and an 8-ounce chocolate milk shake.
A McDonald’s Sausage Biscuit with egg,
one slice of cheese, 30 grams of raw onion and 8 ounces of Borden’s Dutch
An 8-ounce Wendy’s Chili and 8 ounces of
The chili meal with wine produced the greatest numbers of reflux and the
most severe heartburn for the first hour after the meal. The sausage
biscuit meal, which had the highest fat content, produced the most severe
heartburn 90 minutes after the meal. Of all three meals, the sausage
biscuit meal produced the maximum heartburn, heartburn-related symptoms
and acid reflux.33 And you wonder why prescription antacids
are a $7 billion business in the US?
Some Common Medications That Relax the LES34
Calcium channel blockers (blood pressure pills)
Theophylline (for asthma)
Medications for Treating GERD
There are several classes of medications which will offer some relief from
GERD and indigestion.29 Liquid and tablet antacids, H2
receptor antagonists (see below), and proton pump inhibitors (see
below) all reduce the amount of acid in the stomach. Some agents increase
the LES pressure, like bethanecol (Edronax). Alginic acid (Protacid)
forms a protective foam barrier and sucralfate (Carafate) buffers some of
the acid. H2 receptor antagonists may cause mental changes,
increased estrogen activity which can cause enlarged breasts in men, and
changes in the metabolism of other medications.22 There is
some concern that H2 receptor antagonists and proton pump
inhibitors may cause stomach cancer with long term use.34-35
Use any of these medications only as a last resort after you have tried
the simple and safe actions listed at the end of this article.
Liquid and Wafer Antacids:
Proton pump inhibitors:
Putting Out The Flames Forever
Most of my patients throw away their antacids on the first day of my
program at St. Helena Hospital and never have to use them again unless
they eat foods that are known to bother them. I also see almost overnight
improvement in asthma, hoarseness, chronic cough, and sinusitis. They
follow a diet based on starches with the addition of fruits and
vegetables. Most of the food is cooked. In the beginning, their stomach
and esophagus may be so raw from years of over-acidity and acid reflux
that even water causes pain -- they have to allow a few days for the
inflammation to quiet down. In the interim period they sometimes benefit
from antacids in the form of liquids or tablets to neutralize the acid, or
pills to stop the production of acid. Raising the head of the bed by four
to six inches by placing bricks or wood blocks under the head posts is of
great help for those with the most reflux. In those very sensitive cases,
extra care must be taken to eat small meals of plain, well-cooked,
starches, vegetables and fruits. Spices should be avoided; however, sugar
and salt are well-tolerated. Water should be the initial beverage in those
with the most severe symptoms.
considerable damage may have already occurred, to the point of causing LES
dysfunction and a hiatal hernia, almost every patient can find relief with
these simple steps, low in cost and free of side effects:
Ten Actions To Take To Quench the Fire
Consume a plant-based diet, low in fat and high in fiber
Avoid foods which aggravate the indigestion, such as raw onions, green
peppers, cucumbers, radishes, and fruit juices, and hot spices
Eat small meals frequently – Do not over-distend your stomach
Lose weight if you are obese, and wear loose clothing
Give up regular and decaffeinated coffee
Whenever possible avoid medications which lower LES
Raise the head of the bed four to six inches (extra pillows will not
help – they only bend you at the middle)
Avoid lying down within three hours of eating
Stop cigarettes and alcohol
Take antacid medications as a last resort.
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