by Natasha Trenev
Gastroesophageal reﬂux (GER), also known as acid reﬂux, takes place when the contents of your stomach back up out of the stomach and into your esophagus. The stomach content is highly acidic and can ‘burn’ the lining of your esophagus causing heartburn, a painful, burning feeling in the middle of the chest or abdomen. It can also cause bad breath, nausea, painful swallowing, respiratory problems, vomiting and damage to your teeth.
GER is typically used to refer to people who have occasional heartburn, while GERD, the ‘D’ standing for disease, describes a more serious version in which a person experiences heartburn more than twice a week for a few weeks.
GERD can affect anyone, but you’re more likely to experience it if you are overweight, pregnant, taking certain medications, a smoker or regularly exposed to secondhand smoke. GER can also progress as people age if the valve between the esophagus and stomach becomes weak.
For most people, it’s an occasional discomfort, however, anyone experiencing heartburn regularly should seek medical care because, left untreated, it can lead to inﬂammation and swelling of the esophagus to the point of disrupting swallowing, causing respiratory problems, leading to precancerous changes to the esophagus, or Barrett’s esophagus — which can lead to a rare, but deadly type of cancer of the esophagus.
Is There a Microbial Connection?
Several scientiﬁc studies have established the idea that a complex group of microbes that live in our esophagus might play a role in GER. One of the ﬁrst teams to explore this idea was lead by Yang and coworkers at the New York University School of Medicine in 2009. They discovered two distinct groups of microbes living within the esophagus. The ﬁrst type was associated with a normal esophagus and dominated by gram-positive bacteria. The second type was dominated by gram-negative species and occurred more frequently in people with reﬂux issues and Barrett’s esophagus. They concluded their study stating that there was a possible role for dysbiosis in the pathogenesis of reﬂux-related disorders. Dysbiosis meaning a microbial imbalance — in other words the “bad” bacteria might be out of balance and enough of the “good” bacteria may not be present.
Just a few years before, another group from the United Kingdom reported high levels of Campylobacter species (a type of bacteria) in people with Barrett’s esophagus. This was a particularly interesting ﬁnding because Campylobacter species had previously been linked to inﬂammation in the small intestine, gum disease, and even tumor formation in animals. They noted that 57% of the patients with Barrett’s esophagus tested positive for Campylobacter species while none of the control subjects did. Now, there were at least two studies suggesting a link between the bacteria in the esophagus and gastric reﬂux issues. However, it remained unclear if the changes in the bacteria occurred before or after the onset of reﬂux issues. Researchers agreed that larger studies were needed to determine the causal relationship the bacteria might play.
Unfortunately, we are still waiting for those larger studies to be completed so more deﬁnitive conclusions can be made about the cause of reﬂux and the role that microbes, like bacteria, may play. Let’s change gears for a moment and look at some of the most common GERD treatments and how they, too, may be leading to further dysbiosis of the microbes in the body.
The Problems with Proton Pump Inhibitors (PPI’s)
Proton Pump Inhibitors (PPI’s) are the most widely sold and used drugs in the world. Examples of PPI’s include esomeprazole (Nexium), lansoprazole (Prevacid) and omeprazole (Prilosec) among others. They work by lowering the amount of acid your stomach makes and are considered more effective than over-the-counter H2 blockers like cimetidine (Tagamet), famotidine (Pepcid AC), or ranitidine (Zantac). The American Gastroenterological Association lists a number of potential risks of long-term PPI use including kidney disease, dementia, fractures, infections and vitamin/mineral deﬁciencies. While short-term use of PPI’s can be very effective, it’s obvious from the long-term negative effects that a more natural approach without such side effects would be ideal.
The highly acidic environment of the stomach is not only important for the digestion of the food we eat, but also acts as a built-in barrier for pathogens entering the body. By taking medication to lower stomach acid, you may be creating a more welcoming environment for pathogenic viruses, bacteria and fungi to enter the body. In fact, one recent study showed that 46% of patients taking an acid-suppressing medication had bacterial overgrowth in their stomach and in their lungs. The researchers also noted an increased prevalence of potentially pathogenic bacteria like Staphylococcus and Streptococcus in the patients taking acid-suppressing medications. This overgrowth means more pathogens may be present and this leads to an increased risk of infections.
Another study compared fecal samples from 1,827 twins and showed that the bacterial families that increased with PPI use were more likely to be related to those found in the mouth or throat and it was not just an overgrowth of the commensal bacteria known to exist in the healthy gut. Both of these studies indicate that PPI’s may be further adding to the problem of dysbiosis, or imbalance, between the amount of “good” and “bad” bacteria present.
Could Probiotics Help Reﬂux?
If dysbiosis is part of the problem, the next logical question is: Can good probiotic bacteria help restore the microbial imbalance by tipping the scale back toward a friendlier bacterial load? Research on probiotics for reﬂux is relatively new and while the studies have been small, the results have been very promising.
A Chinese study of 80 premature infants concluded that, “…probiotics can signiﬁcantly decrease Gastroesophageal reﬂux in premature infants.” Another study of 42 infants with regurgitation tested the effects of a Lactobacillus-based probiotic and concluded that, “In infants with functional GER, [the probiotic] reduced gastric distention and accelerated gastric emptying. In addition, this probiotic strain seems to diminish the frequency of regurgitation.” In other words, the probiotics were somehow speeding up the time food remained in the stomach. They theorized that by reducing the time food was in the stomach, they were reducing the amount of acid the stomach had to produce to keep up with the digestive processes.
Yet another study, using Biﬁdobacterium- and Lactobacillus-based probiotics, conﬁrmed earlier ﬁndings that patients taking PPI’s had “strong bacterial overgrowth in the stomach and duodenum” compared to non-PPI users. When given the probiotic supplement, they noted a signiﬁcant decrease in fecal levels of total coliforms, E. coli, molds, and yeasts indicating that the probiotics could, “…partially restore the gastric barrier effect against food-borne pathogenic bacteria.”
There’s obviously a need for more clinical research with a larger number of participants and research more speciﬁc to adult reﬂux. However we’ve come a considerably long way from where we were 12 years ago when many still thought that no indigenous bacteria even lived in the human esophagus.
Probiotics have so many well-known beneﬁts it certainly can’t hurt to add this beneﬁcial bacteria to your daily supplement regimen and it may be especially helpful to those taking a PPI who are at a greater risk of developing infections. A single strain probiotic that contains Lactobacillus bulgaricus exclusively could be a GER sufferer’s best choice for better digestion. Under normal conditions, these friendly bacteria in the gut outnumber the unfriendly bacteria, are linked to improved immune function, protect against hostile bacteria, and improve digestion and absorption of food and nutrients — just to name a few.