Acid Reflux with Dr. Steven Sandberg-Lewis: Rational Wellness Podcast 112
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Dr. Steven Sandberg-Lewis discusses Gastroesophageal Reflux Disorder with Dr. Ben Weitz.
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Podcast Highlights
2:57 The more common causes of GERD include Small Intestinal Bacterail Overgrowth (SIBO) with increased gas pressure pushing things upwards, vagal nerve problems, which results in the stomach not emptying as quickly, problems with the lower esophageal sphincter not having tone and allowing reflux, and a hiatal hernia which affects the ability of the esophageal sphincter to keep things out of the esophagus.
4:35 To distinguish the cause of GERD you might consider having your patient do a barium swallow test and an upper endoscopy that looks at the esophagus, stomach, and first portion of the small intestine. Dr. SSL will also do functional testing for hiatal hernia to see if there is a hiatal hernia syndrome. He will also often do Heidelberg testing, which measures the pH of the stomach. You might also want to get pH testing of the lower esophagus, and manometry, which measures the pressure. And SIBO breath testing.
6:06 Dr. SSL finds that with his patients with Reflux, 75% tends to be associated more with too little HCL and 25% are associated with too much acid. Dr. SSL also points out that you can have two types of hypochlorhydria on a Heidelberg. One version the patient will have a pH of 5 or 6 and this is frank hypochlorhydria. There is also hidden hypochlorhydria. We do a series of challenges with a super-saturated bicarbonate and see how long it takes to reacidify. If after the second or third challenge, it takes much longer to reacidify or doesn’t do it at all, then that means that the stomach is not able to produce enough acid to digest a meal, which is what we call hidden hypochlorhydria. Then we can give the person some herbal bitters or some betaine hydrochloride.
10:15 The reasons why so many patients have low stomach acid includes that the patient may have a chronic state of disease or they may have autoimmune disease, such as autoimmune gastritis, where they have antibodies to their parietal cells or they can have anti-intrinsic factor antibodies, which means they can’t absorb B12. These patients will tend to be chronically anemic with a macrocytic, large cell type anemia, not the iron deficiency anemia, though they can have both. With other, more common autoimmune diseases, such as lupus, they can also have low stomach acid.
12:20 SIBO can be a cause of GERD due to pressure from the hydrogen or methane or hydrogen sulfide gas pushing upwards and pushing food and acid up into the esophagus. Methane especially seems to be associated with reflux because it slows down intestinal motility and the normal peristaltic movement downwards. You can have bile reflux as well as acid reflux due to decreased tone of the pyloric valve, allowing bile to reflux up into the stomach and then into the esophagus and this is very irritating to the esophagus and may be a key factor in the cause of Barrett’s, which can progress to dysplasia and eventually to cancer of the esophagus. Proton pump inhibitors may increase the risk for bile reflux and there is a Danish study that shows that patients who took PPIs for their Barrett’s esophagus were more likely to develop esophageal cancer and possibly stomach cancer. Here is the study: Proton pump inhibitor use may not prevent high-grade dysplasia and oesophageal adenocarcinoma in Barrett’s oesophagus: a nationwide study of 9883 patients. According to Dr. SSL, while the American College of Gastroenterology is not ready to accept the concept that PPIs increase risk of esophageal cancer, their new guidelines published two years ago state that PPIs should only be used with patients with Barrett’s to control symptoms and they should not be used to prevent cancer.
18:07 H. Pylori infection in the stomach is often discussed as being a factor in the etiology of reflux. Dr. SSL said that this is wrong. There is a meta-analysis showing that having H. Pylori in your stomach is protective against reflux, protective against Barrett’s esophagus and esophageal cancer. 100% of the world’s population used to have H. Pylori and it is an ancient dominion organism, as Martin Blaser points out in his book, Missing Microbes. H. Pylori is also protective against Crohn’s disease, hay fever, asthma, eczema, laryngeal cancer, reflux, Barrett’s esophagus, and cancer of the esophagus. But less than 10% of Americans have H. Pylori in their stomach, since we’ve been testing and killing it since the 1990s. In fact, if you have reflux and you test for H. Pylori and you treat it, it makes the reflux worse, according to the research. In fact, it would probably be a good idea to take H. Pylori probiotics, if they existed. Here is a meta-analysis paper showing that eradication of H. Pylori is linked with higher–not lower risk of GERD: Helicobacter pylori infection in gastroesophageal disease in asian countries.
We have been describing in general what happens with H. Pylori. To add another layer of detail, which unfortunately complicates the story, of the folks who have H. Pylori, if the H. Pylori colonizes the entire stomach, pangastritis, these people will have about a 1% risk of developing cancer of the stomach, though they will get all of these immune strengthening benefits just mentioned. People who have colonization of the only the bottom of the stomach with H. Pylori, antral gastritis, are the ones who tend to get hyperchlorhydria and might end up with ulcers in the stomach or the duodenum. Thus, H. Pylori can either produce hypochlorhydria, when it’s pangastritis, or H. Pylori can produce hyperchlorhydria, when it’s antral gastritis.
24:49 The reason so many people no longer have H. Pylori is that by age 20 the average person in the US has had 17 courses of antibiotics and by age 40 they have had 30 courses, on average.
29:08 We have all heard about leaky gut, which describes hyperpermeability of the small or large intestine. But there is also leaky stomach and leaky esophagus and leaky mouth and leaky brain. In the esophagus, this is called Dilated Intercellular Spaces, which is present in most cases of reflux as well as in about 30% of patients who don’t complain of reflux. But it is not seen on a biopsy, so it’s often not looked at. It is also common in almost all cases of eosinophilic esophagitis and allergic esophagitis. Research has shown that leaky stomach is increased by taking proton-pump inhibitors and its found a lot of autoimmune conditions.
31:01 To fix GERD, we have to treat the cause. We should start with a low carbohydrate diet or a low fermentation diet, like Norm Robillard talks about with his Fast Tract Diet. If there is SIBO we need to treat the SIBO, especially methane SIBO. You can normalize hiatal hernia by doing visceral manipulation and putting the stomach back into its place. You can improve the lower esophageal sphincter by cutting out the CRAP. C stands for chocolate, coffee, cola drinks, and caffeine in general. R is for refined carbohydrates and for Rx or prescription medicines, such as medications that slow down the gut and contribute to reflux. A is for acid and certain kinds of highly acidic foods that aggravate patients with reflux, and aspirin and NSAIDs, which we know can cause reflux and ulcers. If you have a patient who has hypchlorhydria, then you can treat with bitters or apple cider vinegar before meals or betaine hydrochloride with meals. If they have too much acid, you can use a H2 antagonist like Ranitidine (aka, Zantac) or you can use a natural product with melatonin, with B6 and other B vitamins, and zinc. Some products also contain D-Limolene. One of the products he likes is Endozin by Klaire Labs, which contains zinc carnosine and L-glutamine. Dr. SSL also likes a product from Vital called Heartburn Tx, which contains zinc, L-glutamine, glycine, N-Acetyl Glucosamine, DGL, and Aloe. He recommends his patients take a teaspoon 2-3 times per day before meals.
37:15 The best way to heal the damage to the mucosa in the esophagus is to treat the cause of the GERD. Also, avoid alcohol, which can be very toxic to the entire GI tract. You can also take something like aloe vera and zinc carnosine, or use that Heartburn Tx and make a slurry of it, and swallowing it and not drink any water afterwards, so it coats the esophagus. That way you get both some topical as well as systemic treatment.
Dr. Steven Sandberg-Lewis is a practicing Naturopathic physician for nearly 40 years and he teaches at the National University of Natural Medicine and he wrote a medical textbook, Functional Gastroenterology, now in its 2nd edition. Dr. SSL (as he is often called) practices at 8 Hearts Health and Wellness in Portland, Oregon.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Podcast Transcript
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research, and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes, and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness podcasters, thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and review. That way more people can find out about the Rational Wellness Podcast. Also, if you want to see the video version go to YouTube, weitzchiro YouTube page. If you go to my website, DrWeitz.com, you can get a complete transcript and show notes. So I’m very excited that today we’re going to be talking about a very important topic, gastroesophageal reflux disorder with a very prominent functional medicine doctor, Dr. Steven Sandberg-Lewis.
Gastroesophageal reflux disorder is a very common gastrointestinal condition occurring in up to 20% of Americans. GERD, also known as acid reflux, also known as reflux, 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. Burning in the chest, it could be vomiting, breathing problems, a chronic cough, you could be chronically bad breath, chronic laryngitis, and erosion of the teeth. This can eventually lead to chronic inflammation of the esophagus, it can lead to esophageal strictures, which is a narrowing of the esophagus, and it can lead to Barrett’s esophagus, which is a pre-cancerous condition and eventually can even lead of esophageal cancer. I’m very pleased that we have one of the top functional medicine doctors in the country to join us for a discussion of this important topic, Dr. Steven Sandberg-Lewis.
Dr. Steven Sandberg-Lewis (Dr. SSL) has been a practicing Naturopathic physician for nearly 40 years, and he teaches gastroenterology at the National College of Natural Medicine. He wrote an awesome medical textbook, Functional Gastroenterology, which is now in its second edition. And he lectures all around the world. Dr. Sandberg-Lewis, thank you so much for joining me today.
Dr. SSL: You’re welcome, it’s good to be here.
Dr. Weitz: Is it okay if I call you Dr. SSL?
Dr. SSL: Yeah, everybody does, it’s good. It’s shorter.
Dr. Weitz: Exactly, exactly. So, what are some of the causes of GERD? How should we understand this condition?
Dr. SSL: Well, I’m currently writing a book on it, and I’m trying to take a really complicated topic and not make it more complicated, trying to make it simpler. Let me say some of the more common causes are issues with SIBO, and increased pressure in the abdomen, pushing things upward. Problems with the vagus nerve, and the emptying of the stomach, because if the bag stays full longer, it’s more likely to go up instead of down. That’s related to a lot of different conditions. Problems with the lower esophageal sphincter, not having the tone, and allowing reflux. Then, issues that, probably one of the most common reasons, is hiatal hernia, a sliding hiatal hernia, which pretty much takes the normal connection of the diaphragm muscle, and the lower esophageal sphincter and moves the lower esophageal sphincter by two to three centimeters, or occasionally more, so that these muscles aren’t working together the way they’re supposed to. That changes the ability of the sphincter to keep things out of the esophagus. Those are some of the most common issues.
Dr. Weitz: So, when you get a patient with these GERD symptoms, how do you work it up? What are some of the things you look at? What are some of the tests that you do to try to rule out one of these causes over another?
Dr. SSL: So, a lot of the people that I see have already had imaging either barium swallows, upper endoscopies showing the esophagus, stomach and the first portion of the small intestine. So I might have a lot of information already from those reports, but in addition I do functional testing that doctors can do to check for hiatal hernia, what we call hiatal hernia syndrome if we don’t have imaging. The treatment is the same whether it’s a true hiatal hernia, or what we’re just calling a syndrome. We might also do Heidelberg testing, which we do in our office, which directly measures the pH of the stomach. We sometimes refer patients for pH testing that actually looks at the lower esophagus, to see if the pH is changing, there’s true reflux coming up into the esophagus, and the pressure of that fluid. Manometry, which measure the pressure. These are all things that we might use as well as testing for SIBO.
Dr. Weitz: Okay. Do you think reflux tends to be associated more with too much hydrochloric acid, or too little hydrochloric acid?
Dr. SSL: So that’s the interesting piece, is that when we check people with Heidelberg testing, you know, it’s a certain group, most of the people have reflux. I would say about-
Dr. Weitz: Most of these patients that come in that you’re testing, are they on PPIs already?
Dr. SSL: Many are. And they either want to get off of them, because of chronic side effects or risks, or they’re not working very well. So, what we’ll do is not have them take it the morning of the test, and then we’ll measure. What we find is probably a good average is about 25% of the people that we test that have reflux actually have too much acid. They have Hyperchlorhydria, and probably somewhere between 50% and 75% either have too little acid, or normal acid, both.
Dr. Weitz: Now, I’ve heard you say that before, I listened to an interview you did on Nirala’s podcast. And that number differs from A, what most traditional gastroenterologists think, and I’m friends with Dr. Rahbar and he does a lot of Heidelbergs too. He sort of sees the opposite.
Dr. SSL: So Rahbar is seeing a lot more hypochlorhydria?
Dr. Weitz: Hyper, yeah.
Dr. SSL: Oh, hyper.
Dr. Weitz: Yeah.
Dr. SSL: Okay. Yeah, I’ve heard that. But the thing is that maybe it’s a different patient population.
Dr. Weitz: It might be.
Dr. SSL: But there are two types of hypochlorhydria that we might see on a Heidelberg. One is the patient swallows a capsule, it sends out the pH measurement directly to the computer, and you see right away what it is. And if the pH is five, six, you know right away the person has frank hypochlorhydria. If it’s six and a half, you might even call it achlorhydria, meaning no acid production at all. That’s kind of rare. But then there’s also what we call hidden hypochlorhydria. That’s when we do a series of challenges with a super saturated bicarbonate solution, the patient, it’s a very small amount, like five cc’s of this solution, neutralizes their stomach acid, and we see their pH go, you know if it’s already acid at the beginning of the test, we’ll see the pH go up to close to neutral, six, six and a half. Then we measure how many minutes it takes for it to come back down to acid, so to reacidify. We’ll do up to three of those reacidification challenges in the hour that the patient’s being tested. Then we see, does it take 12 minutes every time? That means they just have pretty normal acid production. If it takes 12 minutes, the second time it takes 15 minutes, the next time it never comes back down, that’s a typical thing we’ll see, never meaning we wait 25 minutes and it’s still not coming down. So the stomach is not able to produce enough acid to reacidify. That’s sort of mimicking a meal. Because we can’t put food in there during the test, it’ll gum up the capsule. So we use this to mimic a meal. So if it’s getting longer and longer like that, we call it hidden hypochlorhydria. Then, we can give the person some bitter herbs, or some betaine hydrochloride, and see if that brings it down. See what works.
Dr. Weitz: Interesting. So, why would a lot of these patients, up to 75% of patients that you see, why do they have low stomach acid?
Dr. SSL: Reasons why people will have low stomach acid? In general, I think it has to do with a chronic state of disease. I think in many chronic diseases, just as we see hypothyroid function in many chronic diseases, even if it’s a functional conversion issue. I think we see those same people tend to have hypochlorhydria. Autoimmune diseases, very common. There’s a whole host of common conditions.
Dr. Weitz: How do autoimmune diseases result in hypochlorhydria?
Dr. SSL: Well, there’s true, what we call, autoimmune gastritis, I don’t think that’s as common. But that’s a condition where people actually have antibodies against their own parietal cells, which are, of course, the cells that make acid and make intrinsic factor to absorb B12. Or they’ll have other kinds of antibodies that also will affect the parietal cells indirectly, like anti-intrinsic factor antibodies. So those people, you’ll generally find them to be chronically anemic with a macrocytic large cell type anemia, not the iron deficiency necessarily, although they can have both. They will tend to get a thinning and a decreased mass of parietal cells, and they just can’t make as much acid. So I think chronic disease in general as well as autoimmune disease, we know lupus tends to have that, it doesn’t have to be just pure autoimmune gastritis, it can be with other autoimmune diseases.
Dr. Weitz: So you mentioned SIBO as the cause of reflux, can you explain how that happens?
Dr. SSL: We think that the major mechanism is whenever, you know, the abdominal cavity separated from the thoracic cavity by the diaphragm, normally we expect to have more pressure in the thorax, in the chest, than in the abdomen. When you have 50, 80, 100 parts-per-million of gas, extra gas production with SIBO in the abdomen, that’s going to increase the intra-abdominal pressure. That’s going to tend to move things upward. So we think that it’s kind of a pressure differential issue. There may be other instances-
Dr. Weitz: The pressure from the gas is produced by SIBO, like the methane and the hydrogen, they’re pushing up on the esophageal sphincter.
Dr. SSL: Or hydrogen sulfide.
Dr. Weitz: Or hydrogen sulfide. The new gas on the block.
Dr. SSL: Yeah. But then it could also be that methane, especially, really slows down the normal peristaltic forward movement, and I think methane, especially, seems to be associated with reflux, with biliary problems, just slowing down all the pipes.
Dr. Weitz: Yeah. How often is reflux really bile reflux as opposed to acid reflux?
Dr. SSL: That’s another one. So here we’re talking about the pyloric valve instead of the lower esophageal sphincter, having decreased tone and allowing bile to reflux back into the stomach. Of course that bile could then further reflux into the esophagus if you have both types, causing a very irritating type of reflux. Personally, from all the research I’ve looked at, I think that this may be the key piece with Barrett’s esophagus. A lot of people with reflux, chronic reflux, don’t get Barrett’s esophagus, and it doesn’t progress further into dysplasia, severe dysplasia, or cancer of the esophagus. I think it’s when people, the people that actually have bile reflux, and that’s refluxing up into the esophagus. We know bile, secondary bile acids are carcinogens, and so I really think that that’s part of the piece of Barrett’s esophagus. It’s interesting too, one study showed that people who didn’t have bile reflux, but had reflux, normal reflux, and took proton-pump inhibitors, 12% of them developed bile reflux as well. So proton-pump inhibitors may actually increase this. There’s a huge Danish study that was done that found that the more assiduously the patients take proton-pump inhibitors for their Barrett’s esophagus, the more likely they are to have more advanced dysplasia and cancer of the esophagus. The same thing was true with stomach cancer in patients that were taking proton-pump inhibitors.
Dr. Weitz: So, in terms of where we are, and in terms of the current research on PPIs, do we think that that’s a conclusion we should be drawing or not yet?
Dr. SSL: Well, let’s put it this way. The American College of Gastroenterology came out with new guidelines about two years ago for proton-pump inhibitor use in Barrett’s esophagus. What they said was, “Don’t use it with every patient with Barrett’s, don’t tell them this is a way to prevent cancer of your esophagus, only give proton-pump inhibitors if it helps relieve symptoms in patients with Barrett’s.” So it’s for symptomatic relief only according to the experts at The American College of Gastroenterology.
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Dr. Weitz: How often is GERD associated with H. Pylori infection?
Dr. SSL: I’m so happy you brought that up. You know, I didn’t list H. Pylori as a cause of reflux, and the reason is, everyone agrees to this meta-analysis show that having H. Pylori in your stomach is protective against reflux, protective against Barrett’s esophagus, and esophageal cancer, also Crohn’s and a whole host of other things. So, nowadays, less than 10% of Americans have H. Pylori in their stomach since we’ve been killing it, testing and killing it, since the 1990s.
Dr. Weitz: Isn’t it a question of how much though rather than having it or not having it?
Dr. SSL: That’s a good question-
Dr. Weitz: Right, because isn’t H. Pylori a normal “commensal” of the stomach?
Dr. SSL: Yes. I highly recommend the book Missing Microbes, which is written by Martin Blaser, who is the Director of the Microbiome Research Center at NYU. Really a great book, well written, fun to read. But really lays out the research that shows that H. Pylori is an ancient dominion organism, as he calls it, that it belongs in the stomach, 100% of the world’s population used to have it. Now we’re down to maybe 7% of Americans, and even fewer kids in America, because they can’t get it from their parents who don’t have it. We think, according to the research, that it’s increasing the risk of all kinds of allergic conditions and autoimmune conditions such as Crohn’s disease, hay fever, asthma, eczema, laryngeal cancer, reflux, Barrett’s esophagus, and cancer of the esophagus. So it’s protective against all those things. One thing I try to talk people out of, if they got tested for H. Pylori because they have reflux, it makes no sense to treat it, because it just increases the risk of all the complex complications and sequela of reflux, it makes reflux worse, according to the research.
Dr. Weitz: Interesting. Because the theory that was told was originally we thought you couldn’t have bacteria in your stomach, because of all the hydrochloric acid, then we were told that this H. Pylori was this bacteria that screwed itself into the wall of the intestine, so were somewhat protective and that it leads to ulcers because the body has to secrete hydrochloric acid to try to get rid of it, and it can’t get rid of it because it’s buried into the wall, and that’s why you end up with hyperchlorhydria, which leads to GERD, and so, therefore getting rid of H. Pylori would reduce the hydrochloric acid secretion, and that would fix your GERD.
Dr. SSL: The thing is, again, I said it’s a really complicated topic, and I’m going to try to not make it … complicate and try to make it less complicated. But the bottom line is when people initially get H. Pylori colonizing in the stomach, they will, according to the research, they will have hyperchlorhydria, for at the least the first three months. H. Pylori then either tends to predominate down in the antrum, the bottom of the stomach, that’s called antral gastritis, or the entire stomach, which is Pangastritis. People who have colonization of the entire stomach, Pangastritis, are the ones that have about a 1% risk of eventually developing cancer of the esophagus … a cancer of the stomach, excuse me. And H. Pylori has a risk of that. But it’s been a 1% risk in the people that have Pangastritis. That’s probably the most common type of H. Pylori gastritis. This gastritis in itself isn’t harmful. Gastritis sounds like it’s a disease, but it’s really just the H. Pylori kind of upregulating the immunity in the stomach, which is what it’s supposed to do when you’re a kid, so you won’t develop all these immune diseases.
Dr. Weitz: Why do we have less H. Pylori? Why do so many people not have it at all?
Dr. SSL: Let me just mention the antral gastritis first. The antral gastritis, we think is a much smaller percentage of people, where it’s just in the bottom of the stomach. Those people actually produce more acid. Those are the people, 5% to 7% of the population, that might end up having ulcers in the stomach, or the duodenum. It’s very much, you know, it’s coordinated with that antral type gastritis, but that’s the rarity. But yeah, those people are more likely to get not the stomach cancer, but the ulcers.
Dr. Weitz: And that was the original story about H. Pylori was this was the way to fix ulcers.
Dr. SSL: Yeah. And it is. In that small population. That’s why even though 100% of the world’s population, before we started killing it, had H. Pylori in their stomachs, still ulcers were only 5% to 7% of the population. It’s because it’s when it’s that antral type gastritis. But when it’s the whole stomach, it tends to reduce acid production. This is one way to get hypochlorhydria is H. Pylori. You might call H. Pylori Pangastritis nature’s proton-pump inhibitor. But it’s all a matter of balance. If people also have chronic degenerative diseases, and autoimmune diseases, and other factors, they may develop more severe deficiencies of acid production. So, just to let you know, H. Pylori can either reduce acid or when it’s down in the antrum, increase acid. I can explain why, but you probably don’t need to explain that right now.
Dr. Weitz: Okay. So why do so many people not have H. Pylori, is it because of the antibiotic use?
Dr. SSL: Yeah. So we are now in the fifth generation of antibiotic use. Average person by age 20 has had 17 courses of antibiotics. By age 40, 30 courses. That’s just average. You and I both see patients who’ve had more than that. And that’s just one factor. But we know that no single antibiotic will eradicate H. Pylori, there’s always a triple therapy with a proton-pump inhibitor and at least two antibiotics that’s used. But research by Blaser and his associates at NYU have shown that repeated courses of antibiotics can definitely weaken or kill H. Pylori, 17 courses over 20 years can do that. Also, say that’s for the adults. But for the newborns, if fewer than 10% of grownups have it, the newborn is not going to get it, because you get it from your mom and your dad, and your brothers and sisters. If you have big families where the kids are all sleeping in one bed, in one room, and they’re crowded, you’re more likely to get H. Pylori when you’re a kid. So you’re less likely to end up with autoimmune and allergic disorders and certain types of cancer. Also, we have cleaner water now, water is a way to get H. Pylori, that’s a good thing. But we’re not getting it from other sources as well. But sometimes antibiotics-
Dr. Weitz: So we need H. pylori probiotics.
Dr. SSL: … yeah. So Martin Blaser, at the end of his lectures and the book, am I giving it away? Spoiler alert, he says that he thinks in the future, when the FDA is not so freaked out about the word H. Pylori, maybe 20 years from now, we will have multi-strain probiotics that are multi-strain H. Pylori, we’ll give that to the newborns, because the parents don’t have it. Maybe we’ll treat it with triple therapy when they get into their 30s or their 40s if they develop ulcers, or lymphoma of the stomach, or a gastric adenocarcinoma, which are known diseases that can be associated, as people get older, with certain strains of H. Pylori.
Dr. Weitz: If we see H. Pylori on a stool test, should we not treat it?
Dr. SSL: So, I have a lecture called H. Pylori, The Only Good H. Pylori Is a Dead H. Pylori, right? So you asked the perfect question. My feeling is that doctors who do stool panels that include H. Pylori, unfortunately, are screening patients that we really don’t want to test. And you’re finding commensal H. Pylori and then killing it. I think it’s really best only to test patients for H. Pylori if they have diseases that are associated with it, and you really don’t want to pick up on the commensal and kill it, because there’s no reason to, in itself it’s not dangerous, unless the person is developing one of these diseases. I think we’ll get better and better about doing this right over the next 10 years or so, but right now there’s just so much, the rule of the land is test and treat. So anyone you test, you treat. So I’m just saying, be careful about who you test. If someone just has reflux, don’t test them. If they just have Barrett’s, don’t test them. If they never had an ulcer, they don’t have stomach cancer, or they’re not developing that, you know, if they’ve had Barrett’s esophagus, they’ve had their stomach biopsied already, and you know if they have dysplasia in their stomach or not. So yeah.
Dr. Weitz: Okay. I’ve heard you mention leaky stomach and leaky esophagus. Can you explain briefly what these are, and what role do they play in GERD?
Dr. SSL: Yeah. A lot of people have seen the research on small intestinal hyperpermeability, and large intestine hyperpermeability.
Dr. Weitz: That’s what we typically call leaky gut.
Dr. SSL: Right. But the truth is, it’s everywhere. So I’m sure dentists will find there’s leaky mouth syndrome, and it’s probably already been shown, but I have-
Dr. Weitz: We have leaky brain barriers.
Dr. SSL: Oh, we know that, yeah, yeah, as well. So, in the esophagus, the research calls it DIS, or Dilated Intercellular Spaces. That’s not something you get from a biopsy because you need electron microscopy to do it, so it’s not looked at. Just like we don’t look at microvilli on a biopsy of the small intestine, because you need electron microscope for that, typically not done. But DIS, or the leaky esophagus so to speak, is present in virtually all patients with reflux. And about 30% of patients who don’t complain of reflux. So it’s a very common thing, and seems to be present in most reflux and in almost all cases of eosinophilic esophagitis, allergic esophagitis, and other conditions like that. Also, research has shown that taking a proton-pump inhibitor increases the permeability of the gastric mucosa, so leaky stomach is increased by taking proton-pump inhibitors. And it’s found in a lot of other autoimmune conditions as well.
Dr. Weitz: So how do we fix GERD? How do we help our patients heal?
Dr. SSL: You fix GERD by treating the cause. So first you have to figure out what’s the cause. We know that low carbohydrate diets, and low fermentation diets in themselves can be a perfect fix for reflux, and Norm Robillard with his diet, Fast Tract Diet, has really shown that. Norm and I were on the same panel at a recent SIBO Conference. As we were talking about all this, he sounded like a one-trick pony. He just kept saying, “It’s all about fermentation. It’s all about carbohydrates.” And you know, by the end of our talk, I kind of felt like he was right. Like every mechanism, the lower esophageal sphincter tone, all these things, they seem to be, let’s say 80% of GERD seem to be related to fermentation. So, he kind of made me a believer, at least I’m entertaining that idea, I think that’s a great way to start.
Dr. Weitz: Yeah, I’ve had Norm on the podcast. So, what other things do we treat? How else do we heal, besides … so if they have SIBO, we were going to use these SIBO protocols, which is probably another whole podcast. But-
Dr. SSL: Yeah, so you treat SIBO, especially methane. You normalize hiatal hernia syndrome by doing visceral manipulation, different kinds of treatment that can put the stomach back in place, and you teach the patient how to reduce the intraabdominal pressure, so it doesn’t recur, less likely to recur. Then you also improve the tone of lower esophageal sphincter, there’s this idea of cut out the CRAP, C-R-A-P, that comes from the book No More Heartburn. C stands for chocolate, coffee, cola drinks, caffeine in general. Sometimes those, the use of those things is a real key piece for people with this problem. R is for refined carbohydrates. It also stands for Rx, or prescription medicines, because we know a lot of medicines that relax spasms, and pain in the gut, and slow down the gut, can cause reflux. A is for acid. Some people, certain kinds of highly acid foods aggravate them, and it’s also for aspirin and NSAIDs.
Dr. Weitz: So, on the acid thing, let’s say we have a patient with low stomach acid, what do we do?
Dr. SSL: Well, if you have a patient with low stomach acid, and you know that from either a trial with vinegar, or betaine hydrochloride, or doing a Heidelberg test, then you can actually treat reflux by using bitters, apple cider vinegar before meals, or betaine hydrochloride with meals. That can be a treatment for hypochlorhydric reflux. So yeah, just depends on the case. There are some patients that using pancreatic enzymes will get rid of the reflux. Maybe because they’re digesting carbohydrates more effectively, brush border enzymes, breaking down their carbohydrates better and that way they’re not getting as much bacterial overgrowth.
Dr. Weitz: How about if they have too much stomach acid?
Dr. SSL: That’s the trickiest one. If they have too much stomach acid, I will admit, I will have a patient at least use, in many cases, at least use a H2 receptor antagonist, such as ranitidine, which has a much lower side effect profile than the proton-pump inhibitors, and we’ll just use the minimum dose that controls it. If we can’t control it by normalizing all the plumbing, and the fluid, and the pressure.
Dr. Weitz: What about natural PPIs? There are some products on the market that contain melatonin, B vitamins, methionine.
Dr. SSL: Melatonin is a really great thing to try. Yeah, that study that used melatonin with B6 and other B vitamins, and zinc, definitely worth the trial. And there’s lots of good products, some in powder form, some in capsules that incorporate a lot of these treatments including D-limonene sometimes in itself just really helps to normalize biocidal protection, normalize the esophagitis.
Dr. Weitz: Do you have a preferred product for that?
Dr. SSL: Am I allowed to say products?
Dr. Weitz: Sure.
Dr. SSL: I really like either Endozin by Klaire Labs, which has a tiny bit of glutamine, and mostly zinc carnosine. D-limonene, I don’t really care where it comes from, seems to be good. But there’s a powdered product from one of these companies, I think it’s either Pure Encapsulations, or I think it’s Pure Encapsulations, which is called Heartburn Tx. And it has gamma oryzanol, and Acetyl-Glucosamine, glutamine, zinc, carnosine, DGL, and a few other, aloe vera, and it’s a really nice mix. And people can take around a teaspoon twice or three times a day before meals, and I think it really gives therapeutic doses of those things.
Dr. Weitz: So, if they have damage to their esophagus, like we were talking about this leaky esophagus, or they have Barrett’s, what’s the best way to heal that?
Dr. SSL: I think the best way to heal it is treat all the known causes that you have that you can come up with.
Dr. Weitz: Yeah, so let’s say we’ve reduced their reflux, but now they still have damage.
Dr. SSL: Yeah. I’m a big believer in the fact that don’t push the river, it flows by itself. So if you fix the cause, you get rid of that chronic inflammation from that reflux, I think you give it some time. Studies show, for instance, patients who … By the way, when we were talking about the C-R-A-P, A also stands for alcohol. For some people, their reflux is caused by alcohol. So studies have shown that-
Dr. Weitz: How does alcohol cause reflux?
Dr. SSL: How?
Dr. Weitz: Yeah.
Dr. SSL: Alcohol is toxic to the entire GI tract, the mucosa throughout the entire GI tract, and is a risk factor when used daily, even social use, there’s a risk factor for SIBO. So, I don’t think you have to look too much further than that, but-
Dr. Weitz: What about alcoholic containing..
Dr. SSL: …alcoholic gastritis as well.
Dr. Weitz: What about alcoholic contained in mouth washes?
Dr. SSL: I hope people aren’t swallowing those. But yeah. I mean, alcohol in mouth wash has been shown to be a carcinogen in the mouth. For squamous cell carcinoma, so they’re tending to remove that from mouth washes these days.
Dr. Weitz: Then, you throw in some antibiotic, and throw in some fluoride…
Dr. SSL: Yeah. I mean, again, if you’re trying to heal a leaky esophagus, I think that using something like aloe vera, and zinc carnosine, or that Heartburn Tx, making a slurry of it, and swallowing that and not drinking any water afterwards, just let it coat the esophagus. That’s a really nice way to get direct treatment right there, and then they’re swallowing it, so it gets systemic as well.
Dr. Weitz: That’s cool. What about food allergies?
Dr. SSL: Food allergies are a big issue. Food allergies is a big issue for all of these conditions. So, you may need to do individual sleuthing to figure out what foods the person is sensitive to, so that you’re not upregulating their immune system constantly.
Dr. Weitz: What’s your favorite form of sleuthing?
Dr. SSL: Well, I don’t do a lot of the IgG, IgA, IgE food testing. I do it when patients ask for it. If I do decide to do it, I tend to use IgG, IgA, unless the patient has classic allergic triad, like eczema, asthma, and hay fever, and then I might do the IgE, IgG. But mostly I’ll use-
Dr. Weitz: Which testing companies do you like the best?
Dr. SSL: I think we tend to use Doctor’s Data.
Dr. Weitz: Okay.
Dr. SSL: Genova does a good test as well. But mostly what I tend to do is use Dr. Siebecker’s SIBO specific diet, and then we have what we call the high five. If they’re not getting significant relief in their reflux from that low-carb, low fermentation diet, I’ll talk to them about the high five, that’s eggs, dairy, even lactose free dairy, the third would be raw fruits and vegetables, the fourth would be too much honey, or sugar from fruit, and the fifth one would be nuts and seeds. So one at a time, they’ll take those things out in addition makes the diet a little more restrictive, but they can find out if any of those particular things is causing their reflux.
Dr. Weitz: Interesting. Can you just repeat those again?
Dr. SSL: The high five?
Dr. Weitz: Yeah.
Dr. SSL: So, the high five, I got this actually from the guys at SCD Lifestyle, they call it the four horsemen of the apocalypse, but I added a fifth, I call it the high five. The first one is eggs, common foods people react to. The second is dairy products, even lactose free dairy products, like 24-hour yogurt. The third one is nuts and seeds. The fourth one would be raw fruits and vegetables, because some people, the fiber is just too much for them initially, especially if they have ileocecal valve syndrome, which is another valve. And the fifth one would be too much honey or fruit.
Dr. Weitz: I’m surprised you don’t have gluten in there.
Dr. SSL: Gluten is already gone on that diet.
Dr. Weitz: Okay.
Dr. SSL: All grains are already gone.
Dr. Weitz: Oh, so they’re already on the low-carb, low fermentation diet.
Dr. SSL: Yeah. First they just do the general SIBO specific diet, and if they’re not having dramatic improvement, then we look at the high five.
Dr. Weitz: I got it. I got it. Good, excellent. Okay, Dr. SSL, I think that’s all the time I have today. This was great, I really appreciate it. How can listeners get a hold of you, or your courses, or your books?
Dr. SSL: My book, right now, I have one textbook, I’m working on a few others, is on Amazon. So if you just google Steven Sandberg-Lewis on Amazon, or Functional Gastroenterology, which is the name of the book. It’s available there. I’m just developing a website I have, I had one for years, but I never did anything with it. Currently, you can find a link to all my articles, Townsend Letter, I have a near monthly column there, which I really like to share with people. Where my current private practice is at 8 Hearts Health and Wellness, you can go to 8, the number 8, Hearts.org, and that website links you to all my articles if you look under my bio.
Dr. Weitz: Are you still accepting patients?
Dr. SSL: Yeah. Yeah. I mean, we have a bit of a waiting list, but I have other doctors that work with me that kind of can speed up the process. I would say too that if you go to the SIBOcenter.com, I believe it is, which is the SIBO Center at NUNM, National University of Natural Medicine, I’m affiliated with them too, and you can find my articles there, and blogs and things as well.
Dr. Weitz: Awesome. Thank you so much for spending the time with us.
Dr. SSL: You’re welcome, it was fun. Nerding out on GERD.
