Reflux / Indigestion / Dyspepsia

The terms reflux, indigestion and dyspepsia are overlapping referring to a complex of symptoms occurring in the upper digestive tract.  They are analogous to the term irritable bowel syndrome which refers to a similar collection of symptoms in the lower digestive tract that may result from several different factors.

 

 

 

 

Dyspepsia literally means “bad digestion”, but the common use of the term now refers to poor digestion that induces symptoms.  It is typically used when the symptoms and the supposed source of the poor digestion are in the stomach area or the “upper GI tract”.

 

Dyspepsia is a symptom complex which may include indigestion, stomach pain or fullness, chest pain, throat pain, sinus drainage and heartburn.  Indigestion typically refers to cases where these symptoms are not caused by true reflux.  It is a general term for a collection of problems that often result in the same symptoms.

It is generally thought that about 25% of persons with dyspeptic symptoms have true reflux type and about 75% have some form of non-reflux indigestion.

The factors that may cause non-reflux indigestion include:

•Dysmotility

•Food sensitivities

•Gallbladder dysfunction

 

Dysmotility simply means poor movement referring to the timing and pacing of the movement of food through the upper GI tract.  Two dominant factors contribute to poor digestive movement including insufficient stomach acid production or hypochlorhydria and imbalance in the autonomic nervous system which controls digestive activity.

Hypochlorhydria is much more common than typically appreciated.  Studies suggest that it occurs in about 10% of young adults.  By age 50 it occurs in 20% and in 70% of adults 70 years and up.  There may be subtle differences in the symptoms of true reflux and hypochlorhydria, but they can be helpful in the differentiation.  A Heidelberg Gastric pH test can be used to definitively diagnose hypochlorhydria.

The second trigger of gastric dysmotility is an imbalance in the autonomic nervous system.  This imbalance is called sympathetic dominance. The autonomic nervous system (ANS) basically runs all functions we do not have to voluntarily think about including blood pressure, heart rate and digestion.  The sympathetic portion of the ANS gets us ready for “fight or flight” raising heart rate, blood pressure, blood glucose, brain alertness and suppressing digestion.  The parasympathetic portion of the ANS activates “rest and repair” including activation of all components of the digestive tract.

The presence of symptoms such as anxiety, depression, sleep disturbance or “brain fog” may be indicators that sympathetic dominance is present.  Their absence, however, does not rule it out.

When sustained or repeated stress has caused ongoing activation of sympathetic “fight or flight”, the ANS learns to stay in that mode, sympathetic dominance. Heart rate variability testing is an accurate way of looking at balance in the ANS to determine if that may be a component of digestive dysfunction.  Specific neural re-training techniques can then be used to resolve sympathetic dominance.

Food sensitivities often cause reflux symptoms as well as mimicking several other functional digestive disorders.

Gluten is perhaps the most common trigger of a food sensitivity reaction although many different foods can also cause them.  Studies examining reflux symptoms in patients with gluten sensitivity find that reflux symptoms are present in over 30%, or one in three.

Food sensitivity testing will isolate which foods may be triggering reflux symptoms and also elucidate the optimal treatment.  It will also help to isolate the cause of other common problems that may be associated with food sensitivities such as joint inflammation, skin problems and brain/neurologic problems.

Gallbladder dysfunction may also cause indigestion/reflux symptoms.  The co-occurrence of indigestion with diarrhea dominant IBS or general digestive intolerance to higher fat meals may suggest gallbladder dysfunction.

Treatment of dyspepsia/indigestion/reflux

It is important to differentiate the types and triggers of the symptoms of dyspepsia/reflux.  The symptoms of reflux and dyspepsia are typically very similar. As treatment decisions are most often made solely from symptom presentation, proton pump inhibiting drugs (PPIs) are used in most patients regardless of the type.  Using these drugs in non-reflux dyspepsia is thought to be the primary reason for the failure of these drugs to help a fairly large number of patients.  Failure of response to PPIs is reported in 50% of the patients with endoscopically proven reflux irritation of the esophagus. Treatment failure is reported as high as 70% in patients where use is based only on the presence of dyspeptic/reflux symptoms.

The broad use of PPIs in dyspepsia is not without risk of adverse effect. These adverse effects are often under-appreciated as they are not apparent in the short-term and occur slowly over time with continued use.  Most of these adverse effects relate to the blocking of normal upper GI digestion because of blocking of the main generator or stomach digestion, hydrochloric acid.  These adverse effects include:

Effect                                                                        Mechanism
– Bone loss                                                                Malabsorption of calcium
                                                                                   Malabsorption of Vitamin D
– IBS                                                                          Loss of bacterial and yeast cleansing
                                                                                   action by gastric acid
– Clostridia bowel infection                                        Disruption of the intestinal microbiome

– Dementia                                                                 Malabsorption of B12 & other nutrients

– Numbness, ataxia, &                                               Malabsorption of magnesium
muscle cramps
– Anemia                                                                    Malabsorption of iron

Given that these are potential adverse effects associated with long-term use of PPIs care should be taken to limit their use to only appropriately selected cases.  Great care should be used in determining the precise mechanism of symptoms in each patient leading to specific treatment programs.

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