Gastroesophageal Reflux with Dr. Ben Weitz

I wanted to share with you today a recent interview I did with Dr. Ben Weitz on his podcast, the Rational Wellness Podcast, where we talked all about GERD, or gastroesophageal reflux disease. I think you’ll like it. It’s a little bit longer than our normal videos, but we get pretty deep into GERD and there’s a lot to say here. We haven’t talked about it much in the past, so I’m hoping you’ll find the information both insightful, interesting, and above all else, hopefully useful.

Dr. R’s Fast Facts

What is Gastroesophageal Reflux Disease (GERD)?

  • The contents of the stomach come back up into the throat, resulting in a burning or acidic taste in the mouth, burning pain in the chest, vomiting, breathing problems, chronic cough, chronic bad breath, chronic laryngitis, and possible erosion of the teeth in longstanding problems.
  • Can eventually lead to chronic inflammation of the esophagus, esophageal stricture, and Barrett’s esophagus.
  • Occurs in up to 20% of Americans.

What causes GERD?

  • A leaky esophagus or weakening or dysfunction of the lower esophageal sphincter that normally prevents stomach acid, bile, and enzymes from traveling back from the stomach up into the esophagus.

Treatment

Surgical Approach

  • Fundoplication – Primary surgical procedure for GERD
  • Upper part for the stomach is wrapped around the lower part of the esophageal sphincter to strengthen the sphincter and prevent acid reflux.

Dr. Ruscio’s Approach

  • Instead of trying and testing for several possibilities all at once, a pyramid approach has shown to be beneficial for the patient from a treatment and financial perspective.
  • Think of diet as the foundation. Changing the diet almost always benefits the patient and puts them in a better position for other treatment. If diet doesn’t bring 100% relief, consider dysbiosis and stomach acid levels.

Diet

  • Elimination diets, whereby most food allergens are removed, are a good place to start.
  • Most eliminate wheat, dairy, spicy food, nightshades.
    • Try a Paleo, Autoimmune Paleo, or the 4/6/8 Food Elimination Diet
    • A low FODMAP diet may also be helpful
    • Listen to your body – which foods work for you or not
    • A low histamine diet could be really helpful as well – reserve this for later on down the road once you’ve tried the others.
  • The underlying cause could be IBS, the symptoms are very similar.

Dysbiosis

H. pylori

  • Documented to have caused stomach ulcers.
  • Does not always cause increased stomach acid.
  • If someone has H. pylori and GERD, it would seem reasonable to treat the H. pylori.

Testing for H. pylori

  • Stool antigen profile, a breath sample, and a blood antibody profile.
  • The combination of three tests ensures a more accurate diagnosis.

SIBO (Small Intestinal Bacterial Overgrowth)

  • SIBO can oftentimes be responsible for IBS.
  • Stands to reason that the treatment of SIBO can also help with GERD.
  • SIBO can cause increased gas pressure.
  • It is possible that a case of SIBO occurs very high up in the small intestine, causing increased gas pressure that may push on the esophageal sphincter, or it may be because of histamine.
  • Motility can be problematic in SIBO, which may contribute to symptoms of GERD.

Diet and treatment

  • Low FODMAP diet has shown to have an 8-fold decrease in levels of histamine.
  • Iberogast, an upper GI prokinetic, has shown to relieve symptoms of dyspepsia and indigestion.
  • Motilpro is another great compound.

Stomach acid levels

  • The symptoms of high or low stomach acid have much overlap.
    • Younger patients – if they report gnawing-type stomach pain or any family or personal history with gastritis or ulcers, there is a likelihood they are having issues with high stomach acid.
    • Older patients that have anemia or autoimmune diseases have an increased probability of having low stomach acid.
      • Good candidates for a trial of supplemental acid.
      • During supplementation trial – take the acid in isolation and notice if symptoms increase or decrease.

Lowering stomach acid

  • Oftentimes this option can be overlooked.
  • Sometimes a period of acid lowering can be helpful and allows the stomach to heal.

Treatments

  • Combination of Melatonin, B vitamins, Betaine, Methionine, Protexid or GI Guard PM.
  • If GI Guard does not work well, use Protexid in its place.
  • These treatments are not recommended for long-term use.

Natural treatments that can relieve symptoms

  • Gut soothing formulas
  • Histamine blocking medications may help to lower stomach acid.

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Gastroesophageal Reflux with Dr. Ben Weitz

Dr. Ben Weitz: Hey, Rational Wellness podcasters. Thank you for joining me again today. This is Dr. Ben Weitz. And we’re going to be speaking about gastroesophageal reflux disorder with our special guest, Dr. Michael Ruscio, today.

So gastroesophageal reflux disorder, also known as GERD or reflux, occurs in up to 20% of Americans. GERD is a condition where the contents from the stomach come back up into the throat, resulting in a burning or acidic taste in the mouth, a burning pain in the chest. There could be vomiting, breathing problems, a chronic cough, chronically bad breath, chronic laryngitis, and possibly erosion of the teeth in long standing, chronic problems.

This can eventually lead to chronic inflammation of the esophagus, esophageal strictures (that means the esophagus actually narrows, and people have trouble swallowing), and Barrett’s esophagus, which is a precancerous condition, and can even lead to esophageal cancer. It is generally believed that the cause of GERD is a leaky esophagus or weakening or dysfunction of the lower esophageal sphincter that normally prevents stomach acid, bile, and enzymes from traveling back from the stomach up into the esophagus where they can cause a burning and inflammation of the sensitive esophageal tissue.

This is why the primary surgical procedure for GERD is the Nissen fundoplicatoin in which the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux.

But from a functional medicine practitioner, this definition really doesn’t help us that much, because we need to know what the underlying cause of GERD is and what other factors it is related to.

And in order to sort this out and to provide some clinically useful information, I’ve asked Dr. Michael Ruscio to join us today. Dr. Ruscio is a doctor of chiropractic, a functional medicine practitioner. He’s a researcher. He’s an educator. And he has a fantastic monthly practitioner training program, which I’ve been enjoying, called the Future of Functional Medicine Review. And you can sign up for that on his website, DrRuscio.com. And he has lectured all around the world with specialties in the gut and thyroid. And he will soon be publishing a long-awaited book.

Dr. Ruscio, thank you for joining me.

Dr. Michael Ruscio: Hi. Thanks for having me.

DrBW: So what do you think are some of the main factors, especially from a functional medicine practitioner, that lead to gastroesophageal reflux?

DrMR: Well, there are a number of things. And the way I like to think about this is more so through an intervention hierarchy, because what I find is oftentimes patients and providers understand mechanisms, but they don’t know how to treat those mechanisms. They don’t know how to treat the mechanisms in the most efficient hierarchy.

So I would like to channel us through a four-point intervention hierarchy that I think will codify all the different mechanisms and treatments into the most logical sequence of steps that one can take.

DrBW: Great!

DrMR: Okay. And the way I always like to approach these things is picturing almost a pyramid in my mind. And we want to start with the foundation of the pyramid with the least invasive, most common items to address first. Oftentimes these are things like diet. And then at the very apex of the pyramid would be something like a surgical procedure, like you outlined a moment ago. And so I think it’s helpful just to try to create that outline in your mind. And we’ll think of this from the foundation upward.

And the base of the pyramid, the foundation, would really be diet. And we’ll get into some specifics there. The second would be dysbiosis or imbalance in bacteria. The third would be stomach acid levels. And then the fourth would be natural treatments that can alleviate some of the symptoms.

But when I say natural treatments, these would be natural treatments that would be similar to a pharmaceutical treatment. There are natural agents that can lower acid just like there are pharmaceutical agents that can lower acid. And so sometimes, we need to use natural agents while we’re addressing the underlying cause.

So when we come back to the first rung of the pyramid, so to speak, food allergies is really the foundation. Now, this is a broad term. Sometimes, this is encapsulated into something like a paleo diet. And people may have heard of the paleo diet, which cuts out very common allergens.

And I’m using the term “allergen” loosely. These may not be technically considered food allergens. They may more befittingly be qualified as food intolerances.

DrBW: Or food sensitivities.

DrMR: Or food sensitivities, right. So without getting overly wrapped up in the nomenclature specifics, just to make this accessible and easy to talk through, foods that may have an inflammatory or reactive component for the person, foods that are typically encapsulated, again, in an elimination-type diet. Paleo or autoimmune paleo are two methods.

If you’re more of a conventionally-minded person or a conventional provider, you may have heard of this has a 4, 6, or 8 food elimination diet. But they all have some similarity in terms of the foods that they remove. Wheat, dairy, caffeine, spicy foods, alcohol, and nightshades are some of the most common ones. And this is a great place to start, because allergens—again, using that term loosely—can provocate GERD and reflux.

And we, as the listener, or potentially a friend that we know, has probably said something along the lines of, “Boy, if I eat X I notice I get indigestion. I get GERD. I get reflux.” So there is certainly this observation that certain foods can provocate this.

And this observation actually reinforces one of the mechanisms of the medications that are often used, which are histamine antagonists, or H2 blockers as they’re known. So certain of the medications actually blunt the effect of histamine.

And histamine is part of the allergic response. So it makes sense that if someone were to be eating foods that cause an allergic-type response that would facilitate histamine, histamine actually has a pro-acid action in the stomach. And that could then cause a feeling of reflux or GERD, because acid levels are going too high. And this is where medications that block histamine actually can lower stomach acid.

DrBW: I’ve also heard it described that because food sensitivities are foods that contain proteins that it’s difficult for your body to break down, that the inability to fully break down a food would also increase the potential for a mechanical reason for GERD. In other words, this undigested food is going to increase the likelihood that it’s going to get pushed back up from the stomach into the esophagus.

DrMR: It’s certainly a possibility. I think that’s more of an inference. I haven’t seen much in the published literature that reaffirms that. But really, it comes back to a simple principle, irrespective of the mechanism, which is try an elimination diet and then reintroduce. And see what foods seem to work for you and what foods don’t seem to work for you.

And fortunately, we have some diets that do a good job with encapsulating the most commonly problematic foods. That would be either the paleo diet, autoimmune paleo diet, or a 4, 6 or 8 food elimination diet, which are going to be very similar.

There are other dietary approaches that can also be used. One may be a low FODMAP diet. And a low FODMAP diet may be helpful for this excess gas that may cause pressure. And I think the low FODMAP diet probably has more merits for helping with GERD than perhaps a protein elimination diet. But of course, if someone does notice a negative reaction to a certain protein, then I of course would advise them to avoid it.

However, where the low FODMAP diet may have additional utility is because it, by definition, by design, is going to limit foods that are prone to be producing gas. And if gas and gas pressure is something that’s pushing up against that lower esophageal sphincter and pushing it open, then reducing foods that produce gas may be helpful.

And the low FODMAP diet has been used in a number of clinical trials for IBS and shown to be helpful. And this is salient, because there has been at least one systematic review that has shown that IBS and GERD have quite a bit of overlap. And as we talk through this list of interventions, if the listener is familiar with treatments for IBS, they’ll likely notice a lot of similarity between treatments for GERD and for IBS, and that’s because the underlying cause may be very much one and the same.

DrBW: I know you try to avoid testing, but I’ve found it’s sometimes helpful to do some testing for food sensitivities. Sometimes, it’s difficult to sort this out. Or sometimes, it’s not the obvious foods like gluten and dairy and soy.

DrMR: Sure. I’m open to testing. It’s not that I try to avoid testing. I try to use testing very judiciously and where most appropriate. And again, totally open to testing. In my experience, I’ve been able to sort out most of the GERD cases that we see—and IBS cases—without having to utilize food allergy testing. But certainly, I’m not opposed to it. It’s just I try to consolidate my testing to the most impactful tests. And this, as you’ve probably heard me harp on, can be very helpful in achieving the most minimal bill for the patient.

DrBW: Sure. I totally understand that.

DrMR: Now, there’s one other dietary piece that I think is worth mentioning. And this may be where sometimes someone may need testing to get them there, because they may not have these other potential diets to run through. And this is where a low histamine diet can come in.

And with what we talked about just a moment ago, a low histamine diet’s utility would make sense. If we’ve established that excessive histamine can push acid levels higher, then it would very much stand to reason that a lower histamine diet could help to lower acid. And this is not something I would start with. This would be something I would reserve for maybe a month or two or three down the road when you’ve gone through some of the other dietary changes and perhaps not seen the ideal response. But if you’ve gone through some of these front line changes with the diet and still not seen response, then a low histamine diet may be helpful.

And you can easily look up a low histamine diet on the internet. You won’t see agreement in every dietary list that you pull up on the internet. That’s because the research that we pull from to establish what food has a lot of histamine compared to what food does not have a lot of histamine—there’s not tight agreement. But if you look at the overlap, there’s a core set of foods that most dietary guidelines will agree on for a low histamine diet.

So I would just recommend not getting caught up and stressing out about the fact that not every diet lines up to a T. But focus on the core group of high histamine foods. And if you do try a trial of the low histamine diet, focus on those foods. Give yourself a few weeks. And usually, one to two weeks on a low histamine diet is enough time to know if it will be helpful for you. And if it’s not after one or two weeks, then move on and keep working through this list that we’re developing.

DrBW: Now, you mentioned high acid. And it’s generally thought by the medical establishment in general that high levels of hydrochloric acid are one of the main causative problems that lead to reflux, GERD. And in the functional medicine community—I’m sure you’re probably going to get to this. But in the functional medicine community, there’s been a big discussion about whether it’s actually decreased hydrochloric acid secretion that’s a factor in GERD.

And we all know about Jonathan Wright’s study. He looked at a bunch of people who were diagnosed with having too much acid. And they really had too little, thus leading to decreased digestion, break down of their food. And giving hydrochloric acid was found to be helpful.

DrMR: To put it very simply, we fact checked Jonathan Wright’s references from his book. And I have to say that none of his references stood up. And I have nothing but respect for Jonathan Wright. And I think he’s nothing but well-intentioned. However, the references were all miscited. In fact, some of the references from his book on stomach acid actually support the opposite of his position, which is, in studies looking at lower esophageal sphincter tone that gave patients acid-lowering medications, they actually showed a tightening or an improved functioning of that sphincter after acid-lowering inventions.

So I think that—I don’t think. When you look at the data and you fact check the references, the references truly don’t support that. Some of this information will be in my book. And I’ll be releasing some of the other information on my website. Some of the information was a little bit too detailed for the book. So I’ll likely just turn that into a blog post. But truly that was not supported.

DrBW: Okay.

DrMR: Now, betaine may actually help with stomach healing. The mechanism may be wrong. But the treatment may stay the same where betaine, as in betaine HCL, may actually help facilitate stomach healing. So it may not be the mechanism that we thought it was or that Wright proposes, which is increased gastric acidification causes a signaling to tighten and close the lower esophageal sphincter. Therefore, if people don’t have enough acid, they don’t have enough closure. And they can have reflux. That mechanism, at least in my experience, does not seem to be correct. But it doesn’t mean that people may not benefit from acid supplementation.

DrBW: Okay. Good. Thank you for clarifying that.

DrMR: Yeah, and I’m happy to because I do think that in the natural medicine community, the functional medicine community, there is an over utilization of stomach acid or hydrochloric acid supplementation.

And what I’ve seen is this can be probably one of the most common misses by either patients trying to self-help themselves or natural-minded providers trying to help patients—giving patients acid who actually have a degree of gastritis.

And the practitioner keeps scratching their head as to why this person still has bloating, still has reflux, still has gas and pressure. And it may be because they’re giving acid. They’re not seeing a positive response to the acid. And they’re not able to conceive of that acid not being helpful. So they’re moving on to other things like SIBO, H. pylori, SIFO. And they’re looking further down the rabbit hole. All the while, they’re missing the fact that this person probably has a degree of gastritis. And these supplemental acids are actually making the gastritis worse.

DrBW: Yeah, and a lot of the practitioners are using the increased amount of acid, a little bit more, a little bit more, another one, another one. And they’re waiting for that burning sensation to back it down.

DrMR: Right, which is another thing I would really recommend against. And I will come to that in a moment. But let me bring us back to that hierarchy just to try to—

DrBW: Sorry to throw you off track.

DrMR: No, totally fine. Totally fine. So the second step would then be dysbiosis, because there are likely a number of people or providers who are going to be counseling with people who don’t see adequate resolution after the diet.

And so the second thing to really consider would be dysbiosis. And this is a broad term. But you can include in there probably two of the most salient forms of dysbiosis, which would be H. pylori and small intestinal bacterial overgrowth.

Now, I don’t classify H. pylori as an infection or as a pathogen because there isn’t universal data showing that H. pylori is actually detrimental. And in fact, there is some evidence that even hints that early colonization with H. pylori may actually be protective to the host, especially from an immunological perspective.

Also because it doesn’t appear that we can fully eradicate H. pylori. It does appear that it’s more an issue of reestablishing a healthy level of colonization rather than strict eradication. And so I think that’s actually important, because sometimes people get wrapped up in this thinking that, “I have H. pylori. Should I have my husband tested and my children tested because we could all be passing it back and forth to one another?”

DrBW: Right.

DrMR: And I do not think that’s accurate, because you never truly get rid of or fully eradicate H. pylori. But rather, it’s like an overgrown bush. And now you trim the bush, and now you have it in the appropriate colonization density. So if you’re kissing your husband, that is not going to change the colonization density.

This would be a number of factors in terms of how healthy the other commensal bacteria are in crowding out and policing that H. pylori, how healthy your gastric system is, how healthy your immune system is. So that’s something that can actually save quite a bit of unneeded testing and treatment.

But H. pylori would, of course, be one that has been documented to cause stomach ulcers. It does not always cause an increase in stomach acid. It does have to do with a region of the stomach that it infects. But in someone who has symptoms, especially in someone that has GERD, if they have H. pylori, I think it’s a very reasonable recommendation to treat that.

And then with small intestinal bacterial overgrowth, the connection…

DrBW: And by the way, what do you think is the best way to test for H. pylori? I know there are a number of tests. There’s a stool test.

DrMR: I routinely will run, if it’s something that’s highly suspected—so in someone that has GERD, for example, or a history of ulcer or an active ulcer or gastritis or a history of gastritis—then I will run a stool antigen profile, a breath sample, and also the blood antibody profile. And the reason for this is because not any one seems to catch it in every patient that seems to be presenting as such.

And what you’ll even sometimes see is a measure that is purported to be more accurate will actually miss it. And then you’ll see it reaffirmed. Perhaps you missed it on the breath, but you see it via blood antibody and via stool antigen recognition. So I like to look at all three fractions personally.

There are really four ways to test. And the fourth is the rapid urease biopsy. But unless you’re going to go in for an endoscopy, that’s not something you’re going to do. So then you’re limited to the breath sample, the blood antibody testing, and the stool antigen assays.

DrBW: Okay. Great.

DrMR: And then with the small intestinal bacterial overgrowth, the connections have been more speculative. But I think we can draw a reasonable inference, or line of inference, when we know that SIBO is oftentimes one of the factors that can be responsible for IBS. And as we discussed earlier, if IBS and GERD have a lot of overlap and SIBO is involved with IBS, then it would stand to reason that the treatment of SIBO could also help with GERD.

Now, part of this may be because SIBO can cause increased gas pressure. And it’s possible that a case of SIBO that occurs very high up in the small intestine near the stomach may cause some increased gas pressure. And that may push on the esophageal sphincter.

Or it may be because of histamine. In fact, I think we have more data to support that histamine may be the connection, because we have seen that a low FODMAP diet, which very much so helps reduce SIBO—or at least we think, because a low FODMAP diet starves SIBO. Low FODMAP diets have shown the ability to cause an eight-fold decrease in the levels of histamine.

So between H. pylori and small intestinal bacterial overgrowth, you can get a lot of yardage out of improvements in GERD with the evaluation and treatment of those two.

DrBW: Great.

DrMR: And then we come to the issue of stomach acid, which would be the third thing to think about. And this would include stomach acid being too high or too low. And I look at these things together where if someone has high stomach acid, their probability of having gastritis, or ulcer, or potentially even GERD is increased. And I do think there’s something to that.

Now, some of the symptoms of indigestion can also be caused by low stomach acid. So this can be hard to sort out, because the symptoms of high and low stomach acid have much overlap. But there are a few things that you can do to help try to determine what way to go clinically.

Now, there are things that put one at increased risk for high stomach acid. Younger patients: a gnawing-type stomach pain, if someone ever reports a negative reaction to supplemental stomach acid, and of course any family or personal history with ulcers or gastritis. All those increase the probability that someone is going to have high stomach acid and would not be a good candidate for supplemental stomach acid.

However, patients that are older and patients that have either anemias or autoimmune diseases have an increased probability of having low stomach acid. So those would be good candidates for a trial of supplemental acid. And the trial is very important.

And when I give someone acid, if they’re exhibiting symptoms of GERD or if I’m suspicious of something like ulcers or gastritis, I oftentimes will have them start the supplemental acid in isolation so that there are no other variables skewing the response. I typically will instruct the patient that this will either make you better or worse. And if it makes you feel worse, after a few days if you’re still feeling worse on it, then discontinue.

And what this likely means is that person has a degree of either high stomach acid and/or they have some gastritis or an ulcer present. And the acid is actually provocating them and making them feel worse. And that’s missed sometimes. I’ve seen a number of patients—I’d say maybe one patient a month has come in from another provider that was not questioning if the acid was part of the problem. And it was a simple observation that led to a lot of improvement. So it’s definitely important to be open to that.

And just to give some numbers, the amount of documented ulcers in this country is about 6.5%. The amount of documented low stomach acid is 2%. Now, we may have more research looking at ulcers than low stomach acid. So part of this may just be not having the equivalent amount of research. However, we do see up to 30 to 40% incidence of low stomach acid in populations with anemia or autoimmunity. So looking at some of this contextual data is important in helping to determine that.

And I think the biggest takeaway is just keeping in mind that not everyone will benefit from stomach acid. If someone has a negative reaction to stomach acid, then you may actually want to go in the complete opposite direction. And there are a number of cases where this is really the difference between success and failure. Every once in a while, there’s a patient that this is really the big miss.

And I’m drawing up a case study for this for the next edition of our clinical newsletter, wherein a patient came in, and the patient was very well educated on diet, probably so well educated to the point where it was almost difficult to manage because every recommendation that you give, they would go on the internet and read about it. And they would like certain things about the recommendation. But they would have a quarrel with certain other things about the recommendation. And this patient was also hyper analytical. So it was a very challenging case type to manage.

We achieved some good response in things like bloating, gas, insomnia, and fatigue with the treatment of small intestinal bacterial overgrowth. But there was still this gnawing stomach pain and this weird anxiety reaction that this patient would have that was also accompanied by the goosebump phenomenon. So there’d be gnawing pain and then this anxiolytic type of reaction with goose bumps.

It was easy to get pulled into thinking that this potentially could have been neurological. But it seemed to me like this may have been gastritis. And so we put him on a protocol to lower stomach acid. And that was the final missing piece that actually allowed him to heal. And it got him from maybe 70% improvement all the way to 100.

So it’s important if you’re trying to self-manage your healthcare or if you’re a doctor trying to help someone, not to overlook the fact that some people do need acid reduction. And when we look at some of the studies in ulcers, for example, there’s an 80-90% heal rate for ulcers when using acid-lowering medication for four to eight weeks.

Now, you don’t have to use a medication. There are natural agents. One study in particular looked at omeprazole, which is a PPI acid-lowering medication, next to a natural agent and showed equivalent success.

But sometimes, a period of acid lowering is actually helpful because it allows the stomach to heal.

DrBW: What are your favorite natural agents for lowering stomach acid?

DrMR: Well, there’s melatonin, which can be helpful. The study I mentioned before used a combination of melatonin, B vitamins, methionine, and also betaine. And that was found to be equivalent to the omeprazole. And there are two formulas that proximate that. One is called Protexid. And I believe this was a formula that was made by the same researcher that performed the trial. And another one is known as GI Guard PM. So either melatonin or Protexid or the GI Guard PM, which has melatonin plus a few other things.

Now, sometimes people don’t react well to melatonin. You dose the melatonin formula, which is the GI Guard PM, at night. And for some people, they sleep great. For other people, they may feel tired the next day. Or it may paradoxically actually interfere with their sleep. So if the GI Guard PM doesn’t work well, we’ll use the Protexid in its place or potentially just melatonin if there’s some kind of reaction. But those two or three are some options.

DrBW: Hey, one more comment about the SIBO connection. I know that one of the causative factors in SIBO is decreased GI motility. And there seems to be some evidence that decreased esophageal motility may be part of GERD. And could it be that the decreased GI motility part of the SIBO affects the esophagus as well?

DrMR: I think that it could. I certainly think that it could. This is probably why there are some drugs and some natural agents that are actually natural prokinetics that help with motility. Iberogast is a natural agent that has several clinical trials that have shown it to be helpful with dyspepsia or indigestion, which oftentimes includes GERD or the symptoms of GERD. And it’s an upper GI prokinetic.

Now, Iberogast was used in one head-to-head trial against another compound known as cisapride, which is a pharmaceutical upper GI prokinetic. So certainly, I think there’s plausibility to this. The motility cells, the ICC cells (interstitial cell of Cajal) run all the way through the gastrointestinal tract. So I certainly think that makes sense.

Also, interestingly, a study was done sampling the small intestinal, including duodenum, and colonic intestinal tissues of healthy patients compared to IBS patients. And they looked at what happened in the IBS patients before they went on a low FODMAP diet and after going onto a low FODMAP diet.

Interestingly, what they found, amongst other things, was a normalization, actually an increased density of serotonin cells in the IBS patients after going on a low FODMAP diet. And they became more like that of the healthy controls.

Now, serotonin is important, amongst other things, because it’s one of the chief neurotransmitters responsible for motility. This is what Iberogast, cisapride, and some of the other medications that are prokinetics actually help to facilitate, which is serotonin signaling.

So a low FODMAP diet, we could draw a reasonable inference, because it increases serotonin cell density, it may actually help with motility.

DrBW: Yeah, we’ve been using MotilPro, which has 5-HTP in it for the same purpose.

DrMR: Another good compound, yeah.

DrBW: Yeah.

DrMR: Yep. Yep, and I’ve been using MotilPro more now that Iberogast, for some odd reason, has been taken off the market in the U.S. unfortunately.

DrBW: Oh, it was taken off the market?

DrMR: Last I understood.

DrBW: Oh, wow!

DrMR: And we were getting ready actually to do a clinical trial with Iberogast. And then the distribution in the United States was ceased.

DrBW: Wow!

DrMR: You can still get it on Amazon. But in terms of direct procurement, other than some stocks on Amazon that are dwindling and probably soon going to dry up, it can’t—

DrBW: And you have no idea why?

DrMR: There’s certain speculation. The company—I believe it’s Medical Futures—that makes Iberogast was acquired by Bayer Pharmaceuticals. And once that happened, I’m assuming that it may be just a product that may not have been making enough money. Or the small number of side effects that have been reported, they were uncomfortable with or didn’t feel the risk was worth the reward from a business perspective.

DrBW: Or it could be detracting from a more profitable drug.

DrMR: Potentially, yeah. But unfortunately, it’s not looking good right now. Now, patients can always buy this on the internet. It’s just more difficult for doctors who want to be able to distribute these things in our offices.

DrBW: Sure.

DrMR: We can’t do that.

DrBW: Yeah, interesting.

DrMR: So that all gives you a pretty good rundown in terms of starting with diet, then looking at dysbiosis, and, if someone is still non-responsive, considering direct acid modulation.

Now, there is one or two other things that one may want to add in at the end of the line there which could be something that can also facilitate healing in the gastrointestinal tract. And there are many different gut-soothing formulas that contain things like aloe and glutamine, zinc. Sometimes you have herbs like slippery elm.

I use a formula known as GI Revive. There are many similar formulas that are going to have a similar cocktail of ingredients. So that is one that can be helpful.

For GERD and indigestion, there’s also a compound known as FDgard which can help with dyspepsia, or indigestion. And the FDgard is more of a natural palliative measure. But that can be helpful in the short term while you’re trying to rebalance the microbiota and give the diet some time to kick in.

But that’s a pretty good rundown of what you can go through to really try to help with your symptoms. I would really try to honor that hierarchy, because people oftentimes want to jump to the newest and greatest test or fancy treatment. And if you jump to the apex of the pyramid without addressing things at the foundation, you’re really likely to have suboptimal results. So it’s just important to keep that in mind.

DrBW: Yeah, another comment. I just saw an article that Dr. Hyman wrote. And he mentioned magnesium deficiency, because you need magnesium to help the sphincter at the bottom of the stomach relax to facilitate the movement of the food. I thought that was interesting.

DrMR: Sure. Sure, I haven’t heard of that. But I’m totally open to it.

DrBW: Great. And so what’s the next step in your hierarchy?

DrMR: That’s really it.

DrBW: Okay. Good, good, good.

DrMR: Yeah, those four steps. And you can really resolve most cases. And actually maybe also mention that if you have a bad case of gastritis or an ulcer, don’t be afraid to use an acid-lowering medication. Like I mentioned a moment ago, there have been very well documented 80-90% heal rate in four to eight weeks when using these medications. The real miss comes when they’re used in the long term.

DrBW: Right.

DrMR: But in my experience, if you address these other foundational factors, then the need to use these in the long term is almost nonexistent. But it doesn’t mean that if you have bad gastritis you should forego using something like a PPI because you read an article that says PPIs can increase your risk of small intestinal bacterial overgrowth. Even if you have small intestinal bacterial overgrowth in that moment, it’s missing the point. We shouldn’t conflate these two different things. Long-term use of acid-suppressing medications can increase your risk of SIBO, yes. But if you have SIBO and you have an active ulcer, then treating the SIBO with things like diets and probiotics and antimicrobial herbs and treating your ulcer at the same time, that is likely going to work much better than just treating the SIBO and hoping that your ulcer goes away all on its own.

DrBW: Right. Yeah, and I would add there’s a whole series of other possible problems with long term use of PPIs: increased risk of C. diff., pneumonia, even heart attacks, hip fracture. So long term, these drugs are very problematic. And unfortunately, they’re often given for long periods of time even though their recommendations are to be used for short periods of time. But conventional doctors don’t know what else to do. So they just have the patient stay on these things for months and years at a time.

DrMR: And that’s where we come in. And I just think it’s important to be the voice of reason. We don’t want to throw the baby out with the bathwater and say, “Just because these things are bad in the long term, yet they’re cheap, oftentimes covered by insurance, and very effective in the short term, we just want to throw them out completely.”

In my experience, most patients have been very appreciative of that willingness to look at both sides, conventional and natural, and craft a cure plan that’s going to borrow from both objectively rather than dogmatically.

DrBW: Awesome! That’s great. Thank you so much. You really provided us with some very useful clinical information in a very organized fashion. So I really appreciate that, Dr. Ruscio.

DrMR: My pleasure.

DrBW: So for practitioners and patients who’d like to get a hold of you, what’s the best way for them to contact you?

DrMR: Well, my website is a great place to plug in. Pretty much everything that I do is accessible through the website, which is DrRuscio.com (D-R-R-U-S-C-I-O.com). We have a weekly video, a weekly podcast, a weekly article. The book will be out in February. And announcements about the book will be there.

And also, if you’re someone who is wanting to get more clinically prescriptive with this information, we do have a monthly publication for clinicians or for lay people who are really interested. And this is the Future of Functional Medicine Review clinical newsletter. And we go through case studies and research studies. And yeah, that all keeps me pretty busy.

DrBW: Great. Thank you so much, Dr. Ruscio.

DrMR: My pleasure.

What do you think? I would like to hear your thoughts or experience with this.

Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.

Discussion

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