Dr Steven Sandberg-Lewis - Redefining Reflux

Speaker 1:

Welcome to The SIBO Doctor Podcast, hosted by Dr. Nirala Jacobi, medical experts. Join us to discuss functional digestive disorders, clinical practice and research as it relates to SIBO and associated conditions. This podcast is intended for SIBO treating practitioners and aims to help educate how we may best serve our SIBO patients. Head over to thesibodoctor.com and sign up to the SIBO Mastery Program and take your SIBO knowledge to expert level. If you are a patient, you can sign up to the SIBO success plan and beat SIBO for good. Please note this podcast series is not intended to diagnose or treat medical conditions. Ask your doctor before initiating any new treatments. And now, over to Dr. Jacobi and the latest episode of the SIBO Doctor Podcast.

Nirala Jacobi:

I'm delighted to have Dr. Steven Sandberg-Lewis back at The SIBO Doctor Podcast. I've interviewed Dr Steven Sandberg-Lewis a few times before on the topic of reflux and GERD and H. pylori, and he's a phenomenal wealth of knowledge. He's been a professor at the National University of Naturopathic Medicine since 1985, focusing on gastroenterology and gut associated physical medicine. He's written a couple of books, several books, actually. He's the author of the medical textbook, Functional Gastroenterology, Assessing and Addressing the Causes of Functional Digestive Disorders. And his most recent book, Let's Be Real About Reflux, is due to be released in February of 2023. So, we are very excited to helping him promote this book because he's so different in his approach. So, very happy to have him back on the podcast. And for those listening that are practitioners, we also had Dr. Steven Sandberg-Lewis out in Australia in 2018 to present a two-day seminar on learning how to conduct a functional gastrointestinal physical exam, which is a wonderful course for practitioners specializing in functional GIT disorders. And you can find that on thesibodoctor.com.

So, welcome back to The SIBO Doctor Podcast, Dr. Steven Sandberg-Lewis, it's just so wonderful to have you back to discuss this really important topic of reflux and GERD and everything to do with stomach acid. It's been four years since we've had you on the podcast, so it's high time that we talk about your new book. So, welcome back.

Steven Sandberg-Lewis:

Thanks a lot. It's great to see you.

Nirala Jacobi:

So, can we start by just saying, or let me just ask you, what was sort of the impetus for you to write this book? Because I've heard you lecture on this topic many times, so I can assume that this was sort of a long time in the making this book for you.

Steven Sandberg-Lewis:

Yeah, I'll tell you, every book that I looked at, whether it was for professionals or for lay people on the topic of gastroesophageal reflux was so simplified. It was so minimal. Basically, in most cases, all about too much acid or acid suppression was the treatment. Even some of the natural books, they focused more on just hypochlorhydria and not enough acid and that you need to take acid. And that's part of the picture. Both of them are part of the picture, but there was nothing out there that was really comprehensive, and I wanted to kind of put it all out there, so people can know.

Nirala Jacobi:

That's fantastic. Yeah, that last episode, we did cover actually a lot also on the whole H. pylori story. And let's try to summarize some of these idea or topics that you will cover in your book. But let's start with that. There is actually more than one type of reflux, and a lot of people just always think as you just mentioned, that it's related to hyperchlorhydria or a high stomach acid. But talk us through what the various types of reflux are.

Steven Sandberg-Lewis:

So, about in my testing in my office with Heidelberg Machine and other doctors that use that to check stomach acid levels, I find about 20% of the people that I test that have reflux make too much acid, probably 50% to 60% make too little acid, and about 20 to 30% make normal amounts of acid. The thing is, normal amounts of acid are a pH less than three, often less than two. So very highly acidic together with pepsin in the stomach can digest meat. I mean, it can digest you made out of meat, so you don't have to have excessive acid to be able to burn your esophagus because esophagus isn't designed to have that kind of level of acid. And if there's excessive reflux, and we'll go through all the reasons why you might have reflux from the stomach into the esophagus, even normal amounts of acid can be an issue.

So, it's all in my way too detailed. Look at all this. It's really a sort of a balance between the protective factors that protect the esophagus and protect the stomach lining as well based or compared to the aggressive factors or the things that can really damage those tissues. And it's really cool how natural medicines, naturopathic treatments and diet and lifestyle can really afford lots more of that protective activity against those aggressive factors and reduce the aggressive factor.

Nirala Jacobi:

Well, and this is a very frequent topic also that I discuss with my patients, because many people that I see that whether they have SIBO or not, they often have upper gut sort of dysfunction, whether that's gastritis or reflux or nausea or those kinds of issues that I sort of look at together as sort of this symphony of events that takes place during digestion. And many people that have been on proton pump inhibitors, they continue to actually have symptoms, but actually that can be often due to a low stomach acid output. Can you talk about why you can have symptoms with low stomach acid that are very much the same as if you have high stomach acid or reflux, I should say? Yeah.

Steven Sandberg-Lewis:

Yeah. So, I didn't fully answer your question. Your first question, which was, what are the different kinds of reflux? So, I just want to say that, at least 50% in some studies, 60% of people that have reflux have no damage, no visible damage to their esophagus. That's called non-erosive reflux disease or NERD. And then, there's a certain percentage, low percentage, but it's there that have damage to their lower esophagus, and that's erosive esophagitis. And they're four different levels of that, that get deeper and more extensive. People with erosive esophagitis actually tend to respond really well, most of them to proton pump inhibitors, those are the people that take proton pump inhibitors and it's magic. They get so much relief and it's just wonderful for them. But at least 40% of people that take proton pump inhibitors don't get any relief. And it might be first of all, that they actually don't even make too much acid to begin with.

Maybe they don't make enough, or they have enough protective factors that they don't have erosions and damage to tissue, they have nerd non erosive. So, it's a different mechanism in those cases. And we can talk more about those mechanisms if you want to. But your question about why someone who doesn't make enough stomach acid could have the same symptoms of heartburn, part of that answer is that just the pressure of fluid coming up into the esophagus can cause symptoms. Some people it causes a burning sensation, heartburn, and other people, it causes chest pain. It just feels like pressure and pain. So, that's one thing. Another thing is most of your listeners have heard of leaky gut or hyperpermeability of the intestine, but there's a type of leaky esophagus, so to speak, they don't use that term, but I like to use that term and it's called dilated intercellular spaces or DIS.

And DIS is when those squamous cells that normally line the esophagus and protected from all kinds of things when the spaces between them spread out. And then, it's possible when you have these dilated intercellular spaces that any fluid, and remember, even if you don't make enough stomach acid, you still have pepsin, which can digest protein, which can digest tissue. So, lots of irritating substances can come up from the stomach into the esophagus, and they can irritate the nerves that are in the deeper layers underneath those squamous cells that line the esophagus. So, that dilated intercellular space could be a really important factor. And it's basically present in almost everyone who has reflux and about 30% of people who don't.

Nirala Jacobi:

And so, also the people that have non erosive reflux disease will often have these dilated intercellular spaces.

Steven Sandberg-Lewis:

Right.

Nirala Jacobi:

And what did you say? What triggers that? Because that's interesting. So, you can have esophageal symptoms based on the gaps between these cells becoming larger, but it's a non-erosive type of esophagitis. Is that what you're saying?

Steven Sandberg-Lewis:

Right. Whether it's erosive esophagitis or non-erosive, this is a very common finding. Let's call it leaky DIS and what causes it. There's not been a lot of research that, I can't really find good explanations of why that occurs. But if we just extrapolate until we know better from what we know about leaky gut, we know that lots of medications, NSAID, ibuprofen and aspirin, we know that alcohol, we know that food sensitivities and actually all kinds of reactions that take place that cause systemic inflammation, including bacterial overgrowth and yeast overgrowth can cause excessive permeability in the small or large intestine. Maybe that's part of what's going on. Maybe this is just the esophageal version of leaky gut.

Nirala Jacobi:

So, talk to us about bile reflux, which is also a really common type of reflux, isn't it?

Steven Sandberg-Lewis:

Yeah. So, the chapter in my book called Bile Reflux, the Next Valve Down Can Reflux too, meaning that here, the pyloric valve that separates systemic from the small intestine, you have reflux through there. And so, it's called bile reflux, but that's kind of dumbed down also, biles coming up, bicarbonates coming up, which is made in the pancreas. Pancreatic enzymes are coming up in the reflux, partially digested food could be coming back up. And bacteria from the small bowel, if you have SIBO, can be coming up into the stomach. So, there are a lot of irritating substances. In fact, even the brush border enzymes that are in the duodenum are also coming up. So, it's quite a brew of things that's coming up. But bile gets top billing because it's known that secondary bile acids are actually carcinogens.

And so, you have this partially carcinogenic mix coming up from the small intestine into the esophagus, and it can be very irritating. The common symptoms from that are in the stomach itself would be nausea, lots of burning kind of pain that's actually in the stomach. And then if that refluxes further through the lower esophageal sphincter into the esophagus, that's probably the most damaging form of gastro esophageal reflux there is because now you have bile, pepsin, acid and all these other things all together irritating the lower esophagus.

Nirala Jacobi:

And what's a common cause of bile reflux? Well, it's hard to, it's usually a clinical diagnosis for me in my office, right, because we're seeing patients, it's very difficult to diagnose it. I think you mentioned before that mostly on endoscopy you can see some biles staining, but sometimes you don't. And it can be sort of a more difficult diagnosis, more based on your clinical response to treatment or to change in diet, et cetera. So, what actually causes this type of reflux?

Steven Sandberg-Lewis:

So, there's very little research on that. Certainly, it makes sense to me if I just tell you what I think is causing it. I think that increased intraabdominal pressure, increased pressure in the small intestine is a major factor that's going to push things up, that can also push the stomach up into the chest, hiatal hernia be one of the factors. So, anything that increases intraabdominal pressure, whether that be abdominal obesity, sometimes pregnancy, holding your breath when you exert someone who either lifts heavy weights and holds their breath, or anyone who does core exercises to strengthen their abdominal muscles but holds their breath when they're doing it, or just excessive lifting with breath holding. People who get constipated and they have hard stools that have to work. They're birthing a baby to get it out, and if they hold their breath to try to get more pressure, that's a big factor that increases the intraabdominal pressure.

They know what they're doing. They want to get more pressure because they want to push things out down the bottom, but unfortunately, they push things up as well, just as likely. And then, if you think about gastroesophageal reflux, if you make an analogy to that, if the lower esophageal sphincter losing tone is a big factor there, then the pylorus losing tone may be an important factor with bile reflux into the stomach. So, anything that affects vagal tone, that controls all these valves, things that affect acetylcholine, the major neurotransmitter in the gut for the parasympathetic and vagal nerve series, these are all very likely factors.

Nirala Jacobi:

One of the things I wanted to talk to you about is the laryngopharyngeal reflux or LPR, which I seem-

Steven Sandberg-Lewis:

LPR.

Nirala Jacobi:

... to see commonly and this connection between the lower esophageal sphincter and also, aging and just this kind of chronic cough that we see. And there's just a lot of issues around lower pressure of on that LES and what can cause that. And so, LPR is just a different, it's a bit of a dark horse in a way because we often don't know it's a type of reflux and we just have a patient that comes in with a chronic cough. And can you talk to us about what causes that? Why are people potentially not more symptomatic for reflux or esophageal reflux with LPR?

Steven Sandberg-Lewis:

Yeah, so LPR or laryngopharyngeal reflux. Laryngo meaning the larynx, the voice box and pharyngeal meaning the pharynx or the upper throat, that's where the reflux symptoms are in LPR. They're not usually not down where you would expect them over the sternum, lower down where most people get heartburn symptoms. And probably the best analogy I can make to that is we call that silent reflux. Well, you can have all kinds of silent problems with diabetes. So for instance, silent heart attacks where people are having a heart attack and they have no pain, they don't really know it, they just feel a little strange. And it's because of the changes in the autonomic nervous system that take place over time with insulin resistance and diabetes. So the autonomic neuropathy is the term for that change in the autonomic nervous system that controls the gut and it's nerve changes in that system as opposed to peripheral neuropathy where people get all kinds of problems in their legs and feet with diabetes and insulin resistance.

So, I think that's a factor. I mean, if you consider that 30% of people now have either pre-diabetes or diabetes, 30% of the population, that's also the group that's obese or overweight. In part, that's probably a big part of it, is that people aren't feeling the heartburn where it's occurring. They're feeling it when it rises higher. And that's called regurgitation when it comes up into the throat. But they don't even have to have regurgitation fluid. It could just be a mist, sort of the gases. It's the venting of the gases from the stomach coming up into the throat and voice box.

Nirala Jacobi:

And how much of whether it's LPR or reflux is due to the sort of relaxation of the LES rather than that there is a pH problem or hyper or hypo acidity.

Steven Sandberg-Lewis:

Yeah. The LES is a big deal. It's a major player here. And there are a couple of important pieces here that I would like people to understand. One is, it's called TLESR, transient lower esophageal sphincter relaxation. So, it has that LES in it, but it has a T at the front and R at the end. Transient lower esophageal sphincter relaxations. That means that if you have an upper endoscopy exam and they don't see that your lower esophageal sphincter is lax or open, sometimes it is, and they'll report that, which is great information. But even if they don't see that, you could have excessive transient lower esophageal sphincter relaxations. And these are normally when you know, swallow some food or liquid, there's this sausage like contraction that moves things down, peristalsis, and that only takes about 10 seconds to go from your mouth to your stomach. That's the esophageal transit time.

Once that moving of the bolus of food or liquid gets down to your lower esophageal sphincter, it opens and as soon as it moves, things move through closes right it up again. That's the way it's supposed to be. TLESR, these relaxations that can occur, that lower esophageal sphincter can stay open for up to 20 seconds, much longer than the typical swallow. And so, it can allow reflux. And guess what the TLESR are for? They have a function, of course, their function is to vent gas and pressure from the stomach. So, people who overeat, people that eat rapidly without chewing and eat a meal in five minutes. It was a fascinating study where they had people eat a meal, the same foods two different days, a meal with the same foods. One day they had them eat it in 30 minutes the next day they had them eat it in five minutes. And the amount of reflux that occurred, and these weren't even people that had reflux normally, they were just average people, the amount of reflux was significantly higher in the five-minute meal.

So, putting too much food in your stomach, which you can do if you eat fast because you don't feel the fullness if for sometimes 20 minutes or just having too much gas in your stomach because you're eating a high fermentation diet or because you have SIBO and some of that gas is getting into your stomach through the pyloric valve. That's what you need these TELSRs for to vent that, so you don't have horrible pain and end up in the emergency room. And that's a big factor for causing reflux.

Nirala Jacobi:

I was also reading about some of the well-known triggers for what we think of is acid reflux is actually, there are triggers for this transient lower esophageal reflux, which is... Or relaxation, I should say TLESR. This is a mouthful.

Steven Sandberg-Lewis:

Yeah.

Nirala Jacobi:

But yeah, some of the same triggers like tomato juice and coffee and mint and things like that can relax this sphincter. And I was also reading about antihistamines and things like progesterone. And can you talk to us about some of these other maybe lesser known triggers for a relaxation of that sphincter?

Steven Sandberg-Lewis:

Well, some of the ones that I came across in the research for the chapter on lifestyle issues and the lower esophageal sphincter, where alcohol, consumption of alcohol, chocolate, and smoking cigarettes. Those are definitely factors that reduced lower esophageal sphincter tone. But I came up with a mnemonic, which by the way, the chapter on lifestyle factors, I pre-published it in the Townsend Letter magazine in October, so you can read that chapter there. It's the full chapter is there in the Townsend Letter. But those are some of the lifestyle factors that really affect the lower esophageal sphincter. But I think that as well with the TLESRs there's another factor, and that is nitric oxide and nitric oxide controls not only blood flow and vasodilation constriction balance, but also inflammation to a large extent. And the tone of muscles, the tone of muscles within blood vessels that allows them to dilate or contract, but also smooth muscle in the digestive tract.

And melatonin is a major factor there. So, I have a whole chapter on melatonin in the book because it's so important for this. And melatonin is part of what we call the GI clock and melatonin. People know that it has to do with waking sleeping cycles. I like to tell people melatonin, it's there to put your digestive tract to bed. It really does more than that, but it controls in part with other hormones. It controls the circadian rhythm and the GI clock that really regulates factors in the GI tract. And it has a major effect on nitric oxide and muscle contraction and relaxation. And if you think about it too, just through the autonomic nervous system, when you are in fight or flight sympathetic dominance, it can overpower the parasympathetic rest and digest part of the autonomic nervous system, which is so important for the control of all the sphincter, including the lower esophageal sphincter.

So, rapid eating, that's probably one mechanism. Rapid eating makes it kind of... My wife Kayla, who's a stress management expert, says that, "If you eat rapidly, you make your brainstem think you're in danger." It thinks, "Oh, they're eating, they're wolfing their food down, they must be ready to run. There must be something that's going to chase them," as opposed to chewing your food thoroughly and slowly and relaxing, which fools your brainstem into thinking you're safe and then nothing's chasing you. So, it allows that parasympathetic activity to control all the valves in your digestive tract.

Nirala Jacobi:

And you said that melatonin has a regulatory function on this, and is there something to consider as a therapy for reflux?

Steven Sandberg-Lewis:

Definitely is. Yeah, that's why I put a whole chapter in it about it in there. And it also has a modulating effect on stomach acid production and LES tone. So, it tends to mildly reduce acid production, which makes sense. If you have more melatonin at 2:00 AM you have more melatonin when your cortisol levels go down at bedtime toward the end of the day, cortisol goes down, down, down, down, if it's working properly, and that allows melatonin to come up. They can't be both up at the same time.

And so, cortisols sort of a big part of that daytime regulation of the GI clock and melatonin, the nighttime, which you don't really need quite as much acid, you're not putting things in your mouth that need to get killed, like bacteria coming in with your food. So, it's a different part of a cycle when you ask before about NERD versus erosive esophagitis, it's a fascinating study that that's in the book that they did looking at taking poor little rats and pumping in acid bile and pepsin into their lower esophagus just with a tube, just like if you had severe reflux going on.

And they did it for two hours in a row and one group, they gave them melatonin first and the other group, they didn't give them extra melatonin. The group that didn't get the melatonin developed erosive esophagitis and or ulcers in the esophagus. The group that got the melatonin were protected and didn't get that. It's fascinating. And there's another study that shows that humans, when they consume melatonin in food, it actually raises the esophageal levels of melatonin, so it does get into the tissue.

Nirala Jacobi:

Wow. Great. And that would be cherries and those kinds of... That's the only food I can remember off the bat that has melatonin in it. Oh, I think rockmelon or cantaloupe, I think also.

Steven Sandberg-Lewis:

Well, this was actually just using preformed melatonin, so-

Nirala Jacobi:

Right, but you were saying that their food. Yeah.

Steven Sandberg-Lewis:

[inaudible 00:30:52] with foods as well.

Nirala Jacobi:

Yeah. With foods. Okay, great. Are there any other sort of clinical pearls or treatments that we can use for tonifying the lower esophageal sphincter?

Steven Sandberg-Lewis:

Yeah. So, one of the things that I have been really impressed with is Huperzine A, so there's a Chinese herb Huperzia serrata, and from it, they get a compound called Huperzine A, Huperzine with a Z like magazine. And this substance is an acetylcholinesterase inhibitors, meaning it helps to keep more acetylcholine in the synaptic space and in the digestive tract in general. So, it improves that neurotransmitter that is so important for the tone of the sphincters and the muscular function. And I've used Huperzine A, I learned this from another doctor many decades ago with people who have known lower esophageal sphincter laxity based on upper endoscopy and seen really great results.

Now, I'll have to tell you, so far the people that have responded the best are young people, teens and people in their 20s. I've had some older individuals that have also responded, but for some reason, I don't know, maybe younger people just have more vitality to begin with, but I'll keep doing it and not give up on the older folks and see if it's working for them too.

In addition, you can use phosphatidylcholine also called lecithin as a precursor for acetylcholine to give the choline that can be converted into acetylcholine, just like those things are used, both Huperzine A and phosphatidylcholine and acetyl L-carnitine and things like that are used to help people with cognitive issues and improve their memory and cognition because acetylcholine is also used in cognition.

Nirala Jacobi:

Right. And it's also used in vagal toning and those substances. That's what we usually associate acetylcholine with.

Steven Sandberg-Lewis:

Yeah. Because this acetylcholine is the neurotransmitter in the vagus nerve and in the on our nervous system, the parasympathetic part.

Nirala Jacobi:

Great. That's a really good tip. I'm going to check that out because that's something I encounter frequently is this issue of the acid is okay or a little low and people still have a lot of reflux symptoms. And I suspect that the LES is really... We don't talk enough about it. I think, and you nailed it when you said that even the alternative community, the focus either on hypo or hyperchlorhydria and not enough of some of these underlying mechanisms that drive this sort of symptomatic picture for many people, and I think it's amazing and a lot of people that may have gone under, but it was so crucial what you said that you only find hyperchlorhydria or too much stomach acid in 20% of your reflux patients. That's to me, like a lot of listeners that are on PPIs or H2 blockers well, ranitidine off the market it's now famotidine, they need to actually tonify their LES and increase their stomach acid for lots of other reasons because it's so vital for digestion and bacteria, static agent and all of that.