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GastroEsophageal Reflux Disease with Dr. Steven Sandberg-Lewis: Rational Wellness Podcast 186

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Dr. Steven Sandberg-Lewis discusses GastroEsophageal Reflux Disease with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on November 19, 2020.

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on YouTube at https://www.youtube.com/user/weitzchiro/]

Podcast Highlights

3:00  Dr. SSL pointed out that reflux and heartburn and regurgitation are not well understood even by physicians.  According to the GI physiology books, reflux is a normal occurrence.  There can be up to three minimal reflux events from the stomach into the lower esophagus that are considered physiologic after meals.  But if there is adequate saliva and normal motility that help to move the refluxed material back into the stomach, there will not be any symptoms.  If it becomes more severe and lasts longer and the protective mechanisms are not there, it can cause GERD. The term gastroesophageal reflux disease means that you have reflux that either leads to symptoms, injury to the mucosa, such as erosive esophagitis, or both.

5:14  Diagnosis of GERD.  You can have reflux without there being any esophageal lesions or ulcerations or Barrett’s esophagus in order to diagnose GERD.  There is something called NERD, which is non-erosive reflux disease, and these patients do not show any visible abnormalities on upper endoscopy.  The way to diagnose GERD is to do a combination of the 4 following tests:

1. Upper endoscopy looking at the esophagus, the stomach and at least the first two portions of the duodenum.

2. Esophageal manometry.

3. 24 hour pH impedance, aka the Bravo test. 

4. Gastric emptying study.

The upper endoscopy is a good way to differentiate whether there’s any gross or microscopic changes that might be intestinal metaplasia or Barrett’s esophagus. Barrett’s is a way for the esophagus to protect itself from this chronic inflammation and irritation resulting from reflux.  If you see dysplasia, esp. severe dysplasia, that is a stage before esophageal cancer. Fortunately, even with Barrett’s, the risk of cancer is relatively low–about 1%.  Esophageal manometry measures the contractions of the esophagus to see the motility.  The 24 hour pH impedance is an indwelling pH meter that shows how often the person is having reflux and whether the reflux is acidic, neutral or even alkaline.  The patient pushes a button when they have symptoms of heartburn to see if there is a correlation.

12:00  Not everybody who has heartburn has regurgitation.  Regurgitation involves a rise of the gastric contents into the throat or mouth, which some people call vomiting into their mouth and then swallowing it again.  Heartburn, on the other hand, is more of an angina-like substernal experience that doesn’t necessarily rise into the throat.

12:55  You can have regurgitation without GERD, which is called rumination syndrome.  Some people can actually control this and use it to take drugs across the border.  But for most people it’s unpleasant and it results from a problem with motility and the treatment is to learn diaphragmatic breathing because the diaphragm is the outer sleeve of the lower esophageal sphincter.  There are manual therapy techniques that can help to pull the stomach down through the diaphragm to its proper position below the diaphragm.  Reflux can lead to hoarseness, a chronic cough, and chronic sore throats.  It can even erode the enamel of their teeth.  Reflux can be a cause of chronic ear infections in kids.

20:05  There’s a condition called Laryngeal Reflux or LPR, which is a form of reflux where patients have no heartburn but they will have some of those extra-esophageal symptoms like chronic throat clearing, chronic cough, chronic sore throat, wake up with a sore throat in the morning, and even chronic pneumonia.  These patients may be having acid, pepsin, bile, and even digestive enzymes from the small intestine getting into their lungs, which can be very irritating.  You can get tonsilar hypertrophy and you can get airway obstruction from laryngospasm.

21:52  The underlying pathophysiological causes of GERD include: 1. Hiatal Hernia, 2. Decreased defenses, 3. Impaired esophageal motility, 4. Increased intra-abdominal pressure like SIBO, 5. Reduced LES pressure, 6. Visceral hypersensitivity.

1. Hiatal hernia, which can also cause arrhythmia, including atrial fibrillation.

2. Anything that decreases the defenses of the mucus membrane, like saliva that is acidic instead of being alkaline. The average person swallows up to one and a half livers of saliva, which contains defensins and lactoferrin, which helps prevents infection and inflammation. One thing that can cause acidic saliva is overgrowth of P. gingivalis or strep mutans that creates an imbalance in the oral biome.  When you have an increase in acid producing flora, this predisposes towards cavities and gingivitis and reduces the buffering effect of normal saliva.  In order to improve this, you can do oil pulling with coconut oil or sesame oil or ozonated olive oil or ozonated coconut oil.  You suck the oil back and forth between the teeth for 15-20 minutes after brushing your teeth.  After you spit it out, let the coating that it puts on your teeth stay there.  This reduces the acid producing bacteria and helps normalize the biome in the mouth. You can also use Edgar Cayce’s Glyco-thymoline oral rinse.

29:00  3. Impaired esophageal motility. We do not know if any of the drugs or natural products for improving gut motility will help with esophageal motility, but it is worth trying them out.  Esophageal motility is related to vagal activity but it is different than gut motility, since it is not related to the migrating motor complex.

31:14  4. Increased intra-abdominal pressure. Small Intestinal Bacterial Overgrowth (SIBO) is the overgrowth of bacteria or archea in the small intestine that can result in gas that increases intra-abdominal pressure.  Pregnancy is also a problem since you have upward pressure and you also have the hormone relaxin that relaxes all the ligaments including the tone of the lower esophageal sphincter, which can lead to more reflux.  Also, abdominal obesity can result in increased intra-abdominal pressure. Also breath holding can be a factor, so you should teach your patients to do proper diaphragmatic breathing.  Hiatal hernia can make proper breathing difficult with part of the stomach contents both below and above the diaphragm.

36:42  5. Reduced LES pressure or tone.  This is affected by many things, including tobacco use, and sometimes it’s hypermobility syndrome, such as patients with Ehlers-Danlos syndrome.  Such patients are also more prone to hiatal hernia as well as to loss of ileocecal valve tone.  They are also prone to visceroptosis, which is a tendency for the stomach, small intestine, and colon to prolapse and hang down.  There are some doctors who do neurotherapy injections into the lower esophageal sphincter to help restore tone, including Dr. Ilana Gurevich.  These patients tend not to do as well with high velocity/low amplitude adjustments and can benefit from PRP and stem cell injections, strength training, and Barral therapy.

41:57  6. Visceral hypersensitivity. These patients perceive peristalsis as painful. Neurofeedback and pulsed electromagnetic field techniques can be helpful.  Low dose naltrexone is sometimes helpful and certain strains of probiotics can help. 

45:01  7. Gastroparesis or delayed gastric emptying.  If the stomach is full for long periods of time and doesn’t empty, you’re much more likely to get reflux up into the top of the esophagus.  This is especially common in type I and type II diabetes, so getting a gastric emptying study can be really helpful.

46:08  Is there too much acid with reflux?  Sometimes reflux symptoms are due to excess acid and sometimes they are not.  Acid reflux can cause erosive esophagitis, including LA grade A, B, C, D erosive esophagitis.  But there can be neutral reflux or weakly acid reflux, abbreviated WAR, or even alkaline reflux, which often results from bile refluxing through the pyloric sphincter into the stomach.  There may also be bicarbonate from the pancreas and the Brunner’s glands of the small intestine.  There can also be functional heartburn where patients have heartburn symptoms but they don’t have any reflux of stomach contents. There are several theories why this may happen, including symptoms that occur that has nothing to do with being full but more to do with something called dilated intercellular spaces, DIS, which are also present in every patient with reflux and it may make the nerves in the esophagus closer to the surface and more likely to be irritated by any secretions in the esophagus. It is essentially leaky esophagus, though it doesn’t get reported on an upper esophageal biopsy because you need an electron microscope to see it.  This is one reason why a patient can take a proton-pump inhibitor and see no improvement with their heartburn.  One thing to check for these patients is the pancreatic elastase on the stool test and while the lab cutoff is usually 200, if elastase is less than 500, say 227, then this can still be a problem and you should try them on enzymes.  You should try plant enzymes, plant enzymes with brush border enzymes, brush border enzymes, porcine pancreatic enzymes and try several different potencies.  Different enzymes work in different pH ranges.  Dr. SSL likes SIBB-Zymes from Klaire Labs.  Apex Energetics has a good product and there is Similase from Integrative Therapeutics, which has some sucrase, lactase and a few other starch digestive enzymes.  The pancreatic enzymes start the process and then the brush border enzymes finish the digestion of oligosaccharides, esp. the disaccharides. If you don’t fully digest your dissacharides because you have brush border enzyme deficiency, you can end up with massive bacterial overgrowth because you are feeding the bacteria all that sugar because you are not absorbing it.

57:12  You may need to evaluate hormones, esp. adrenal steroids and melatonin. Dr. SSL likes to use the DUTCH test for hormones. You also want to rule out hydrogen SIBO and methane IMO. We used to refer to methane SIBO, but since it is caused by archaea rather than bacteria, we now call it Intestinal Methanogen Overgrowth.  There are also food sensitivities including, gluten or lactose intolerance, that can be major causes of heartburn.  Gastric pH levels can be evaluated with the Heidelberg test.  If you suspect hypochlorhydria, you can do a trial with apple cider vinegar or bitters or betaine hydrochloride in a careful way and see if that dramatically improves their reflux, then you know that they’re probably hypochlorhydric.

1:01:16  Herbal bitters can help to stimulate digestive enzymes, hydrochloric acid, bile, and can even help with tonifying some of the valves in the GI tract.

1:03:06 You should evaluate the GI flora, including for H. pylori, and treating it may be an important thing to do. On the other hand, H. pylori can also be commensal and sometimes should not be treated. If your patient has H. pylori and CagA or VacA virulence factors, then the H. pylori is more likely to be pathological.  If the patient has gastric lymphoma, or MALToma, then you should definitely treat the H. pylori, because such tumors have an 84% success rate with treating H. pylori. There are some patients who have chronic iron deficiency anemia that doesn’t respond and if they have positive H. pylori and you treat it, the iron deficiency goes away. The H. pylori was taking the iron from the patient. You can test for H. pylori with a stool test, a breath test, or a blood antibody test.  Dr. SSL noted that he usually does not treat H. pylori very often, but if he were going to, he would use triple therapy, consisting of two antibiotics such as clarithromycin with either metronidazole or amoxicillin plus a proton pump inhibitor for 14 days. He would add lactoferrin at least 300 mg three times per day. He would also add a biofilm disruptor like NAC and also add a probiotic.

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, including remote consults via video or phone, 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. Phone or video consulting with Dr. Weitz is available.

Podcast Transcript

Dr. Weitz:            Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.

So today, our topic is gastroesophogeal reflux disorder or disease with Dr. Steven Sandberg-Lewis. And, this condition occurs in up to 20% of Americans. GERD also known as acid 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 pain in the chest, vomiting, breathing problems, chronic cough, chronically bad breath, chronic laryngitis and erosion of the teeth. This can eventually lead to chronic inflammation of the esophagus, esophageal strictures or narrowing of the esophagus, Barrett’s esophagus, which is a precancerous condition.  And, it can even lead to esophageal cancer. I mean, I’m very excited that we have one of the top functional medicine doctors to join us for a discussion on this important topic, Dr. Steven Sandberg-Lewis or Dr. SSL as his patients often call him.  Dr. Sandberg Lewis has been a practicing naturopathic physician for nearly 40 years, specializing in gastrointestinal disorders. He teaches gastroenterology at the National College of Natural Medicine. He lectures around the world, or at least used to when we used to have in-person meetings, and hopefully we will soon. And, he wrote an awesome medical textbook, Functional Gastroenterology, which is now in its second edition. And, everybody should pick that up. So Dr. SSL, you have the floor.

Dr. SSL:                 All right. Thanks. Nice to join you on your discussion here. And, I’ll share my screen. I just made a little short PowerPoint to give us a kind of a place to start. All right.  So, I find that reflux and heartburn and regurgitation are things that aren’t always very well understood even by well-versed physicians. So, I have a few basic things here to just point out. According to the GI physiology books, reflux is a normal occurrence, apparently up to three minimal reflux events from the stomach into the lower esophagus are considered physiologic after meals. Now, that doesn’t mean that everybody has significant reflux, because if it’s only a small amount, if there’s adequate saliva to buffer it, if there is normal motility in the esophagus, which these contractions that can occur, that don’t require a swallow called secondary contractions, that help to move the refluxed material back down into the stomach.   And, a number of other protective mechanisms that keep it from causing any real symptoms. So, just to know that it can be physiological to have some reflux, although if it becomes a more severe, larger volumes and lasting longer, and the protective factors aren’t there, it can start to cause GERD. And, the term gastroesophageal reflux disease really means reflux that leads to either symptoms, injury to the mucosa, such as erosive esophagitis or both. So, there’s normal reflux that doesn’t lead to disease.

Dr. Weitz:            Now, are there specific criteria for diagnosing GERD or can it be diagnosed simply by symptoms?

Dr. SSL:                 Yeah, I’m going to talk about that in the next slide. It’s a great question. I’ll come back to that. So, there don’t need to be esophageal lesions, erosions, ulcerations or Barrett’s esophagus, or any changes like that in order to diagnose reflux. Because, there’s something called NERD, non-erosive reflux disease, where people have significant reflux, but they don’t have any biopsy based changes or even gross visible changes on upper endoscopy. So, we’ll talk more about that. And, it is true that the majority of people with even true reflux, true GERD don’t show any visible abnormalities on upper endoscopy and that’s the NERD.  So, if someone has significant symptoms of heartburn, and they’re going to get worked up because it’s not getting better, or there’s a concern that they may be developing complications, the way to really find out if someone has reflux is to do some combination of the following four tests. The first one would be upper endoscopy looking at the esophagus, the stomach and at least the first two portions of the duodenum, EGD, based for short. And, that’s a great way to differentiate whether there’s any reflux esophagitis or not, whether it’s NERD or GERD. It’s a way to check for gross or microscopic changes that might be intestinal metaplasia, or Barrett’s esophagus. And really, that’s Barrett’s esophagus is pretty much related to the esophagus trying to protect itself from this chronic inflammation and irritation, from reflux that’s occurring on a regular basis.  And of course, the biopsy would also show if Barrett’s is moving more toward cancer. If you start to see dysplasia, and especially advanced or severe dysplasia, which is a stage right before cancer of the esophagus, and then, esophageal adenocarcinoma. The good news is that even with Barrett’s, especially in women, if they have Barrett’s, the risk of getting cancer of the esophagus is something like 1%. So, it’s a low risk, but much higher risk, then of course, if they didn’t have chronic reflux. And, there are things we can do to help prevent that and reverse it. So, that’s a lot of what I do with patients. Then there’s esophageal manometry, which measures to see if the contractions of the esophagus are normal, whether they have a esophageal motility disorder, which could cause similar symptoms, even if there isn’t reflux.

                                And then, there’s the 24 hour pH impedance, some times it’s called a Bravo test. And, it’s an indwelling pH meter that shows how often, in a 24 hour period, the person is having reflux and whether the reflux is acidic, neutral or even alkaline, which is all really good information. And then, it also allows the patient to push a button, just like a halter monitor for cardiac issues. It allows them to push a button whenever they have symptoms of heartburn. And then, we can see if there’s a correlation between their symptoms and the reflux. And, all those things are helpful for actually truly knowing if the person’s problem is related to reflux. And then, there’s a gastric emptying study that measures to see how much food remains in the stomach at each hour, over a four hour period. Take an x-ray each hour and see how much of the test meal is left in the stomach.  And of course, delayed gastric emptying or gastro-paresis is a major cause of severe reflux, and nausea, and, or vomiting and pain. So, this is the workup that at least the manometry, the upper endoscopy and the 24 hour pH impedance would be done for any patient that is considering getting a Nissen fundoplication or other surgery for reflux. Because, the last thing a surgeon wants to do is do a surgery for somebody who really doesn’t have reflux. So, you’ve got to prove they have it in order to do a surgery, that’s only going to work for reflux. And so, these are things to consider. You may have patients that have had heartburn for decades, and they’ve been on proton pump inhibitors for decades, and they want to get off. And, that’s a reasonable thing to do to help them wean, if you know what they have, if you know exactly. Do they have reflux and what kind of reflux?

                                So, we’ll talk about different kinds. Just a quick slide to show the LA classification of erosive esophagitis or reflux esophagitis. And, grade A is just these little breaks in the tissue that, they talk about the percentage of the circumference that’s affected and how long the fissures are or erosions are. And, you can see with grade C and D you’re getting much more erosion occurring. And, it becomes more of a circumferential issue. And, these are things that show up on upper endoscopy. The clinical manifestations, Ben gave us a nice overview. I just want to differentiate between heartburn and regurgitation. Not everybody has regurgitation, even if they have reflux into the lower esophagus. Regurgitation, I define as the rising of the gastric contents into the throat or mouth, which is a unpleasant experience. Some people call it, vomiting into their mouth and then swallowing it again.  And, that’s regurgitation. Whereas a heartburn often is more of a angina like precordial experience, substernal experience that doesn’t necessarily rise into the throat.

Dr. Weitz:            Can you have regurgitation without having GERD?

Dr. SSL:                 Well, yes. I didn’t put a slide in about that, but it’s a good question. And, there is a condition that I really like you all to know that is not reflux, but it does cause regurgitation. It’s called rumination syndrome. Please don’t mix this up with vomiting or reflux. There is some reflux involved in it, but it’s, it’s a whole different thing. And you don’t see it very often, but I’ve had at least five or 10 patients over the years that have rumination syndrome. And, if you think of a ruminant animal, like a cow, they chew their cud. They’ve got a stomach that has four chambers.  They swallow the grass and it stays in the stomach, goes through different chambers of the stomach, it’s ground up. Then they regurgitate it back into the mouth and they chew it again for a while, and then they swallow it again. So, this rumination is the ability to have food come back up from the stomach into the mouth. And, this happens in some people. And, when it’s involuntary, some people actually have control over it and they use it, I guess, to make money taking drugs across the border. Because, they can swallow them and then bring them back up again. I think they’re called mules, those people. But most people, it’s an unpleasant thing that they can’t control. And so, they’re eating a meal and they’ll say, “All of a sudden 10 minutes after a meal or hour after a meal, my food starts coming back up into my mouth and it’s really embarrassing.” And, “I’m in the middle of doing a lecture and it’s terrible.”   So, rumination syndrome is a whole separate thing from this. And usually, with rumination syndrome, what comes up doesn’t feel like acid, doesn’t feel like it’s burning, it’s just their foods coming back up. And, I won’t go into any more detail about it, but sometimes I’ve seen patients like this, and the diagnosis they’ve got from previous physicians is persistent vomiting. It’s not vomiting, there’s no nausea and there’s no retching. There’s no muscular traction that’s felt, and there is no nausea.

Dr. Weitz:            So, what causes that condition?

Dr. SSL:               Well, it’s considered to be just a variety of motility, that’s a variant of motility. And, the good news is you can read about this in the Rome criteria book that talks about all the functional gastroenterology conditions. But, the treatment is to learn diaphragmatic breathing, and to practice it daily until they’re really understand how to control their diaphragm. They say, “At least a 100 days in a row, they have to practice this diaphragmatic breathing.” And, it can really change this pattern, because the diaphragm really is the outer… I should have put this picture in. The diaphragm really is the outer sleeve of the lower esophageal sphincter.  When the stomach is in the proper position, if they don’t have a hiatal hernia, the two crura or legs of the diaphragm wrap around the gastroesophageal junction, and create an outer muscular coat around the lower esophageal sphincter, making it much more functional. That’s why, if someone develops a hiatal hernia and their stomach moves up two or three centimeters, now the lower esophageal sphincter is up here and the diaphragm’s down here, and they’re not working together, they’re discoordinated. So, the better the functioning of the diaphragm, the better people will be at being able to keep their food in their stomach and not have it rise. It seems to be quite a efficacious treatment.

Dr. Weitz:            And of course, when you have that hiatal hernia, that’s where manual therapy techniques, which you’re an expert at and teach to help pull the stomach down through the diaphragm, right?

Dr. SSL:               To its proper position below the diaphragm. Yeah. Now, Ben also mentioned some extra esophageal symptoms and signs like hoarseness, chronic nonproductive cough, asthma that seems to get aggravated by reflux, symptoms in the throat, chronic sore throats. Even like you said, “Erosion of dental enamel.” I’ve had some patients whose dentists put coating, like a plastic coating on their teeth just to protect it from all the acid. So, they wouldn’t lose their enamel until we actually treated them. And then, they didn’t need that anymore. Chronic sinusitis, even chronic otitis. A fascinating thing is that there’s research that was done quite a while ago, showing that kids with recurrent otitis media, if they checked the middle ear fluid, they found pepsin in it. So, they’re laying down at night, and they get reflux, and the stomach contents go up, they actually end up with pepsin going through the station tube into the middle ear.

Dr. Weitz:            Wow.

Dr. SSL:               And, that’s part of the irritation. In some cases, not every kid. Pulmonary fibrosis, a really feared complication of often not knowing what the cause is, but chronic reflux can really aggravate this and make it progress. Tonsillar hypertrophy, so your patients who have huge tonsils, there’s a study that found that reflux can cause the lingual… Not the lingual tonsil, the regular tonsil, pharyngeal tonsil to increase its mass by three and a half times.

Dr. Weitz:            Wow.

Dr. SSL:               Just that chronic irritation. Other things can do it too, but that’s one of the things that can cause tonsillar hypertrophy. I mentioned the recurrent of otitis media, and then sleep disturbances, sleep apnea, just due to irritation in the throat and swelling. So, if you’re not aware of LPR, laryngopharyngeal reflux is a form of reflex that is unique. And often, these people have no heartburn. They have no symptoms of heartburn, but instead their symptoms are in their pharynx or larynx.   And so, they have some of those extra esophageal symptoms that we talked about, like the chronic throat clearing, chronic cough, chronic sore throat, wake up with a sore throat in the morning, every morning, bad breath, globus phenomenon, feeling that there’s a ball or something in throat. Of course, recurrent aspiration pneumonia, because if you’re aspirating some of those stomach contents, which can include everything from acid, pepsin, partially digested food, pancreatic enzymes and bile from the small intestine, because some people have reflux through the pyloric valve as well. Yeah, that’s a pretty irritating thing to breathe into your lungs. And so, if you have patients that have recurrent pneumonia, you really have to consider this.  If they develop webs or strictures, they can have trouble swallowing, things getting stuck. I mentioned the hoarseness and changes in voice. And even, airway obstruction where they get laryngospasm, and they have symptoms like asthma.  But really, it’s more that their larynx is spasming rather than their bronchioles.

                            So, let’s talk about some of these underlying physiological causes, or pathophysiological causes. These are the factors that can really lead to reflux. And, you can have combinations of them, its not just one. People can have two or three of them, and it makes it more complicated when they do. So we mentioned, “Hiatal hernia.” And, in standard medicine, hiatal hernia is considered something that can cause reflux and nothing else.  But, we know that hiatal hernia can actually cause arrhythmia, including atrial fibrillation, can be a trigger for it. It can cause a lot of the symptoms that we talked about that are extra esophageal and…

Dr. Weitz:            We got the vagal nerve to heart connection.

Dr. SSL:               Yeah. There are different theories about what it is about having a portion of your stomach pushing against maybe the vagus or pushing against the atria that may trigger this atrial fibrillation. But in any case, hiatal hernia can cause all kinds of symptoms, and fatigue and anxiety are two of them. So it’s a good idea to check for hiatal hernia with at least a functional test in any patient who has persistent anxiety that’s not responding, is my feeling. So another thing that can cause symptoms of reflux, heartburn and other reflux symptoms is anything that decreases the defenses of the mucus membrane. So if they have abnormal saliva. Some people have acidic saliva instead of alkaline saliva. And saliva think about it, we think about saliva as like it’s this thing in your mouth, but really up to one and a half liters of saliva being produced every day by the salivary glands and being swallowed throughout the day periodically. That’s a lot of functional material, one and a half liters of saliva.

                                And it’s got defensins in it, it’s got lactoferrin, it helps prevent infection, it helps prevent inflammation. It’s got the alkalinity that helps neutralize any physiologically refluxed, if it’s not excessive, amount of reflux. And the acids from the stomach, assuming the patient has acid in their stomach and just many, many important functions that it has. So saliva is an important thing. If your patient has Sjogren’s syndrome or some other cause of sicca syndrome, they have a dry mouth, that’s a risk factor for esophagitis. And of course, having a normal esophageal mucosa, if they already have erosions, they’re not going to have very good defenses against any reflux material.

Dr. Weitz:            And why would you have acidic saliva? Is that due to diet?

Dr. SSL:               I actually did a talk on the oral biome just last month at a conference, a virtual conference. And the main reason that we think people have acidic saliva is overgrowth of either Porphyromonas or strep mutans in the mouth. So it’s an imbalance in the oral flora.

Dr. Weitz:            So Porphyromonas, you’re talking about P. gingivalis?

Dr. SSL:               Yeah, P. Gingivalis, thank you, yeah. So yeah, it’s thought to be an increase in acid producing variant flora, which predispose toward cavities and gingivitis and reduce the buffering effect of normal saliva for stomach acid.

Dr. Weitz:            Not to take you too off topic, but are there clinical strategies for improving that, changing that?

Dr. SSL:               Yeah. Have me back. I did a whole hour on that and there are lots of great therapies that can help that. I’ll tell you the simplest one right off would be to use oil pulling, and you can use either coconut oil or Sesame oil typically, occasionally ozonated olive oil is used as well or ozonated coconut oil. And that’s kind of sucking the oil back and forth between the teeth for 15 to 20 minutes each night after you’ve brushed your teeth. It’s the last thing you do. And you just let it stay in there, after you spit it out, just let the coating that it puts on your teeth and gums stay there. And that can really help to reduce the acid producing bacteria and help normalize the biofilms in the mouth.

Dr. Weitz:            Wow. That’s a great clinical pearl right there.

Dr. SSL:               Yeah. And there are lots of other great treatments too, like Glyco-Thymoline. If you know the Edgar Cayce’s product in Virginia Beach. Is that Virginia? Edgar Cayce products. They’ve been making this Glyco-Thymoline product for probably 50 to 75 years. And it’s one of the three American Dental Association approved products for an oral rinse to treat gingivitis. So really, if you’re not checking your patients for gingivitis, looking for swollen or edematous or red gums or people who are having their gums are receding, that’s a really important thing to do if you’re treating any GI disorders, because people are swallowing a liter and a half of infected saliva every day, which is inoculating their digestive track. So it’s a really good thing to look for.

Dr. Weitz:            Somebody asked, is it safe to do oil pulling with coconut oil plus adding essential oils like clove or frankincense?

Dr. SSL:               I don’t know. I didn’t research that, I just researched Sesame or coconut oil or ozonated olive oil. So I don’t see any problem with it, but I don’t have any experience with it. Another one would be impaired esophageal clearance. So I talked about that manometry, esophageal manometry test. That would show if someone had a motility disorder. So for instance, if you have a patient with scleroderma, or CREST syndrome, which is sort of a milder form of scleroderma, they’re going to have problems with this because the worst case scenario is called rubber-hose esophagus. And that’s part of the CREST syndrome, right? CREST, E is for esophageal motility problems. And yeah, people with scleroderma have a lot of digestive disorders, especially reflux and reflux esophagitis, motility disorders of the esophagus, so things tend to get stuck, dysphasia. And almost all of them have bacterial overgrowth of the stomach and the small bowel because of the motility disorder of the thickening of the tissue.

Dr. Weitz:            Do any of the supplements that we use for motility of the gut help with motility of the esophagus?

Dr. SSL:               It’s a great question. I have not seen studies on prokinetics to help with esophageal motility. I try them out, but I don’t know that, there’s no esophagus-specific prokinetic agent because it has a different system of motility than the stomach and the small bowel, which is based on motilin as a hormone and the migrating motor complex. The migrating motor complex doesn’t seem to have a connection to the esophagus. That’s that’s another part of vagal function and central functioning. So it’s a great question. I don’t have a perfect answer for it.

                            Next, we have increased intra-abdominal pressure. And as I just mentioned, bacterial overgrowth would be one of those things because gas gets produced by excessive bacteria or archaea making methane or desulfovibrio bacteria, and others that make hydrogen sulfide. And all of that can increase the intra-abdominal pressure. And if it’s greater than the intrathoracic pressure, things are going to tend to move up much more easily, and reflex becomes common. So gas is a problem. Pregnancy could be a problem. Luckily, it only lasts a certain amount of time. And we know that, of course, in pregnancy, you also have the hormone relaxin being produced by the placenta, which relaxes all the ligaments in the body and can also relax the tone of the lower esophageal sphincter and lead to more reflux. And the pressure of the enlarging gravid uterus, as it comes up and pushes up against the stomach and pushes it sometimes up through the diaphragm, is a perfect way to get a hiatal hernia during pregnancy, especially when you’ve got that relaxin flowing through your body, making all of your tissues more flexible, or less elastic and more stretchy.

                                Also obesity, abdominal obesity, especially apple fat can increase the pressure. And we know that abdominal obesity is a risk factor for reflux. And then breath holding. So really important to teach your patients how to do proper diaphragmatic breathing and learn how to feel that as a normal way of breathing, because people that are doing the shallow thoracic chest breathing tend to have issues with changes in pressure between intrathoracic and intraabdominal and more likely to have reflux. Remember too, everything heads back to hiatal hernia. I hate to sound like a broken record, but breath holding, this is a good thing to check when you’re actually with your patient or you’re watching them on telemedicine. When they talk, listen to the sound of their voice. If they talk like this, that means their diaphragm’s locked up.

                                And sometimes that’s because their stomach is partially above and partially below the diaphragm, it’s like an hourglass kind of stomach. And think about it. Are you going to feel comfortable with diaphragmatic excursion if you’ve got this space occupying lesion above and below your diaphragm? It’s really going to impede, for a lot of people, it will impede their functioning of their diaphragm. And they have shortness of breath. They feel like they can’t take a full breath. You’re not going to teach that person how to do diaphragmatic breathing until you resolve their hiatal hernia. It’s just too hard to do. So remember, diaphragm and hiatal hernia, they’re just intimately related.

Dr. Weitz:            By the way, you have a course available where you teach your manual therapy techniques, don’t you?

Dr. SSL:               Yeah. And not just hernia reduction, but also the diaphragmatic technique to help take the spasms out of the diaphragm. Yeah, there was a course that was done. I actually had a wonderful experience going to the Gold Coast of Australia.

Dr. Weitz:            Oh, Nirala Jacobi.

Dr. SSL:               Nirala Jacobi set it up. We had 82 people. It was way too many people to do a manual training, but it was fantastic. And there were these bank of windows looking out at the beach. It was crazy. It was so good.

Dr. Weitz:            You can go to Nirala Jacobi’s website and you can purchase that course.

Dr. SSL:               Yeah. And Nirala is so good at organizing things. It was incredible.

Dr. Weitz:            Somebody just asked a question, have you tried Biocidin oral rinse for improving new oral microbiome?

Dr. SSL:               That is another good option. I haven’t used Biocidin for that, but I know that they they have a toothpaste and they have a similar approach to Glyco-Thymoline, which is volatile oils. So I think that that’s another option.

Dr. Weitz:            Okay.

Dr. SSL:               Next one is reduced LES pressure, tone, and many things can affect that. And sometimes it’s tobacco use, sometimes it’s hypermobility syndrome. So it’s really good to check all your patients for Ehlers-Danlos hypermobility syndrome, because by the way, they’re much more prone to hiatal hernia. They’re much more prone to LES reduced tone. They’re more prone to ileocecal valve loss of tone, open ileocecal valve. And they’re prone to visceroptosis, a tendency for the stomach, small intestine and colon to prolapse and hang down. And that can really affect function of the digestive tract.

Dr. Weitz:            If you have a patient and you find out they have Ehlers-Danlos syndrome, how does that change your clinical approach?

Dr. SSL:                 Well, the good news is full blown Ehlers-Danlos hypermobility syndrome, and there are seven different forms of Ehlers-Danlos. The other six are much more serious and life-threatening. But the hypermobility type is the most common. It’s reported to be about 1% in the United States. In some countries, in some areas of Africa, there are some tribes that have up to a 48% hypermobility syndrome, it’s a genetic finding. But about 1%. So you’re not going to find it that often, but if you do a lot of work with reflux and ileocecal valve and LES, like I do, you’ll find variants of it in a lot of your patients. And I think that knowing that your patients has hypermobility syndrome, I can’t say we have many, many excellent treatments for it, but I can tell you some of them.

                                So by the way, if you want to learn more about this, either have me come back and I’ll talk about it and we can do that or go to the Ehlers-Danlos, I think it’s just called Ehlers-Danlos Society website, and they have a physician or healthcare practitioners section of their website. And it tells you how to do a Beighton score and how to check for category two, criterion two factors as well. There’s just a number of different tests. I do this on every new patient on my telemedicine visits because you can do it with telemedicine. It’s just a really important thing to know about people.  There are doctors that do neurotherapy injections that can do injections into the LES. It sounds crazy and scary, but yeah, one of my good friends here in Portland, Dr. Ilana Gurevich.

Dr. Weitz:            Yeah, I just interviewed her a few weeks ago on my podcast.

Dr. SSL:                 Yeah. She does injections into the LES for patients whose LES tone is poor and aren’t responding to other things. You could talk to her about that. But I think even more important is to know what not to do. So I tend to tell these people use non-force manipulation techniques. Don’t become more and more hyper-mobile by getting high velocity, low amplitude frequent therapy. And I tell them that.

Dr. Weitz:            And don’t go to yoga.

Dr. SSL:               Well, no, yoga’s okay. If it says that the person’s a yoga teacher on their new patient form, you better test them for this because they probably have it because they can do the things that you see in the books that other people can’t do because-

Dr. Weitz:            No, I’m sure they could do it safely. But on the other hand, they probably are not going to benefit from yoga. They would probably benefit from strength training more.

Dr. SSL:               Yeah, well, they could benefit from strengthening so that they have more support and stability in their joints and doing a balanced approach, not just stretching. And if they need it, injections, whether it’s PRP or prolotherapy or stem cell injections, can be lifesaving for these people. As well as, like I say, sort of non-force, more of those types of manipulation. And Barral therapy can be lifesaving as well. Barral is so gentle, but it can really improve the positioning and the mobility of the organs with respect to one another in the abdomen.

Dr. Weitz:            Okay.

Dr. SSL:               And then last two here, we have visceral hypersensitivity, and these are people that perceive peristalsis as pain. Boy, that’s a tough one. There are some treatments for it, specifically biofeedback techniques like neurofeedback can be really helpful. There are some pulsed electromagnetic field techniques that can be helpful. And there are some drugs like low dose naltrexone is sometimes really helpful as well as some probiotics. There are some specific strains of probiotics that have been shown to help with this sensitivity.

Dr. Weitz:            And there’s at least one study that shows that curcumin is beneficial as well. Somebody asked, what was this Barral therapy you mentioned?

Dr. SSL:                 Yeah. So Barral, Barral. Barral was a French osteopath, I believe, who came up with this non-force visceral manipulation technique, which is very elegant. And boy, we have some Barral practitioners in Portland that do amazing things. This is just an aside, but I have a patient who has severe hypermobility syndrome and she was moving into kidney failure. She’s been at about 60 or 58 on her glomerular filtration rate for many years. And we just kind of watch it and try to prevent any problems. And suddenly, she had dropped, her GFR dropped down into the 30s, low 30s, and she was scheduled to meet with an nephrologist. And we gave her some herbs that we use that are protective for the kidneys, but the main thing was she went and had this Barral treatment and they found that her renal arteries were being compressed by surrounding organs. And they just did this gentle manipulation and her GFR went back up. It went up to 58.

Dr. Weitz:            Wow.

Dr. SSL:                 So it’s almost back to 62, like it was. So we’re watching that now. And yeah, it was just incredible.

Dr. Weitz:            Which strain of probiotics helps with gut hypersensitivity?

Dr. SSL:                 The one that was studied, I believe. You can look on Probiotic Advisor for more of this. But I think it’s Align, that regular store brand, was found to be helpful.

Dr. Weitz:            Okay.

Dr. SSL:                 And the last one is gastroparesis or delayed gastric emptying because if you think about it, if the bag is full for long periods of time and doesn’t empty through the bottom, through the pylorus into the small intestine, you’re much more likely to get reflux up the top into the esophagus. And this is especially common in both type one and type two diabetes. If your patient has type one diabetes and their blood sugar is not super well controlled, they have up to a 40, depends on the study you look at, but 40 even 50% risk of getting gastroparesis. So getting a gastric emptying study can be really helpful.

Dr. Weitz:            Hey doc, can you tip your camera a little bit because on video, your top of your head’s getting cut off. There you go. That’s good.

Dr. SSL:                 You don’t need to look at me anyway, but yeah, I’ll do that. Yeah. So this is all the things that can cause reflux symptoms and they’re probably more, but these are some of the big ones. So, the question about acid, is it always too much acid?   Well, sometimes it is, but sometimes it ain’t. So, not all reflux symptoms are due to excess acid, and I just want to point out here that these same reflux symptoms and even true GERD or NERD can be due to acid reflux. Acid reflux can cause erosive esophagitis, or sometimes, not. It may cause some LA grade A, B, C, D erosive esophagitis, or it may not.  And if it doesn’t, we call it NERD, right? Non-erosive reflux disease, but it’s not always acid. Sometimes people have neutral reflux, and there’s a lot of research on this, or what’s called weakly acid reflux, or for short, WAR, W-A-R. I think gastroenterology has some of the best three-letter abbreviations of any form of medicine, any specialty.  So, we’ve got WAR going on here with weakly acidic reflux, and that can cause reflux symptoms as well, or even neutral pH of seven. There’s even alkaline reflux, which is often related to bile reflux through the pyloric sphincter into the stomach.  So you got bicarbonate from the pancreas and the Brunner’s glands of the small intestine membrane coming back up into the stomach together with bile, which may be alkaline. And then you’re refluxing that into the esophagus as well. So that can be alkaline reflux; I didn’t mention that there.  And then there’s functional heartburn, which are people that have heartburn symptoms, identical symptoms, but they actually don’t have any reflux of stomach contents. And it’s a different mechanism.

Dr. Weitz:            What is that mechanism?

Dr. SSL:                 Well, there are a number of theories. One is that any pressure in the esophagus, food moving down or secretions, anything that causes fullness in the esophagus, or a swallowing disorder where food doesn’t make it all the way to the stomach the first time, all of those things can cause symptoms either that feel like burning or symptoms that feel like pain, like angina or chest pain.  So there’s functional chest pain and functional heartburn. And it’s just thought that there’s also something called dilated intercellular spaces, DIS, dilated intercellular spaces. And this is present in virtually every patient with reflux.  It doesn’t get reported on an upper esophageal biopsy because you need an electron microscope to see it. And they don’t typically do that on biopsies, they just use light microscopy. But it’s this spacing out of the epithelial cells that make up the esophagus that which are squamous cells. So, it’s basically, leaky gut of the esophagus.  And the research says it’s almost a hundred percent of patients that have any type of heartburn or reflux of any cause tend to have these dilated intercellular spaces. So that may sort of make the nerves in the esophagus closer to the surface, or more likely to be irritated by any secretions in the esophagus. So different theories as to why that occurs.  But it’s not reflux, and it’s not going to respond usually to standard treatments, which are aimed at getting rid of acid. So one reason why heartburn can persist when someone takes a proton-pump inhibitor, well, of course, one reason would be they already had alpha and reflux or non-acid reflux.  But if they did have acid reflux taking a proton-pump inhibitor, if it works well will lead to weakly acidic reflux. And weakly acidic reflux, according to the research, can still cause the same heartburn symptoms, especially if you have dilated intercellular spaces, which almost everybody with reflux has. And I just mentioned here that it could also be due to the fact that they didn’t have acid reflux in the first place, and it was more neutral reflux.  So, about 40% of people don’t respond to PPIs. And this is my put it all together kind of slide, which we can use as a jumping-off point for discussing different mechanisms. But patients with heartburn or pyrosis, kind of a way to think about it, if you think it’s been going on a long time, and they might have something like Barrett’s or precancerous condition or reflux esophagitis that’s getting severe, you may want to refer for some of these tests.

                                You may want to evaluate for pancreatic function by doing a stool chymotrypsin or stool elastase, fecal elastase, and if it’s low by treating pancreatic insufficiency, sometimes you get a beautiful reduction in reflux. And so it’s always a good thing to check.  By the way, I have a chapter in my book on the pancreas, and in my second edition, I decided the cutoff point is less than 200 for elastase. If the stool elastase is under 200, then they have pancreatic insufficiency, and you can use that as a diagnostic code if you want to, if you’re a diagnostician.  But most patients that you test that have normal elastase, it’s greater than 500, and they won’t even measure usually. I think GI-MAP is the only lab that will tell you it’s 733. Most labs just say greater than 500, because who cares? It’s perfect.    So my recommendation, if you see a patient who has… Like just this week, I had a patient whose fecal elastase was 227, that’s only 27 points away from pancreatic insufficiency, and it’s 250 points away from ideal level, 275 points away from ideal levels. So, I’m probably going to do a trial with pancreatic enzymes with that patient.  And I’m going to try plant enzymes, plant enzymes plus brush border enzymes, pork-based, porcine, pancreatin. I’m going to try several different ones before I give up and say, “This isn’t helping.” Because they’re all very different.  And I wrote a blog, if you go to Hive Mind Medicine, I put my website on the first slide, hmmpdx.com, Hive Mind Medicine Portland, PDX. There’s a blog that I wrote explaining about the different types of pancreatic enzymes and brush border enzymes, and my theories on why that’s important, and how you have to try different ones because they work in different pH ranges.  So, don’t give up if your patient has a, definitely, if they have below 200, or if they’re approaching 200, give it a good try with a number of different enzymes in different potencies before you give up.

Dr. Weitz:            What brush border enzyme product do you like?

Dr. SSL:               Oh, this is a place where we can talk about that?

Dr. Weitz:            Yep.

Dr. SSL:               Okay. [crosstalk 00:09:04]… where I can’t do that. So, Klaire Labs makes a product called SIBB-Zymes, S-I-B-B stands for Small Intestine Brush Border, SIBB-Zymes. And I’ve had very nice results with that.   There is a product by Apex Energetics that is also… I don’t remember the name of it because I don’t use it that much. But occasionally, I have patients that are already taking it. And it’s a combination of a bunch of different brush border enzymes. And I’ve had people do really well with that too. So those are a few.

Dr. Weitz:            Okay, good.

Dr. SSL:               And then products like, many of the plant enzyme products will have brush border enzymes in addition to pancreatic enzymes, they just kind of throw some in. Like [crosstalk 00:09:55].

Dr. Weitz:            What is some of the names that we should be looking for?

Dr. SSL:               Well, for instance, Similase from Integrative Therapeutics. It has some sucrase and some lactase, and a few other starch digestive enzymes. So sometimes they’ll just kind of pepper it with some of those.  And remember, the brush border enzymes are the second phase because the pancreatic enzymes start the process, and then the brush border enzymes finish the digestion of oligosaccharides, especially disaccharides.  And if you don’t fully digest the disaccharides because you have a brush border enzyme deficiency, you’re going to end up with massive bacterial overgrowth because you’re feeding the bacteria all that sugar because you’re not absorbing it.

Dr. Weitz:            Roxanne Yana informed us that the Apex product is known as GlutenFlam.

Dr. SSL:               GlutenFlam might be one of them. They have another one that isn’t so much for the inflammation, but it’s more of a digestive enzyme. They may have several of them, but that would be one of them.

Dr. Weitz:            Okay.

Dr. SSL:               So, that’s pancreas. And then, you may need to evaluate hormones, especially adrenal steroids and melatonin. I use the DUTCH test often, and it measures melatonin levels, but DiagnosTechs lab also does a melatonin along with their adrenal steroids. That could be a whole other discussion right there about how important that is.  You want to rule out hydrogen SIBO and methane IMO, which is Intestinal Methanogen Overgrowth. For many years, we used to call methane a type of SIBO, but because methane isn’t made by bacteria, it’s made by Archaea, we always felt funny about saying small intestine bacterial overgrowth methane type because it’s not made by bacteria. So, now we call it Intestinal Methanogen Overgrowth when it’s elevated methane.

                                And then, of course, food sensitivities including, gluten or lactose intolerance, can be major causes of heartburn. And a lot of patients will tell you, “Oh yeah, I got diagnosed with celiac disease, I stopped eating gluten, and my terrible heartburn went away. I don’t have to take any medicine anymore.”

                                Of course, you can evaluate gastric pH directly with the Heidelberg test. We do that in my office, and we were talking earlier about Sam Rahbar down in L.A. uses that in his office as well. You can do a trial with apple cider vinegar or bitters or betaine hydrochloride in a careful way and see if that dramatically improves their reflux, then you know that they’re probably hypochlorhydric.  The cool thing about the Heidelberg test is if you find that the patient directly measures the pH of the stomach through a capsule, a radio-telemetry capsule, and sends that message out to the computer, and it gives you a graph and near real-time And if you find the patient is hypochlorhydric, you can give them bitters and see what happens to the pH. And we’ve found that a lot of patients, it’ll drop their pH by as much as two pH points when you put the bitters in there.  So you can see if it works for them or not. And if it doesn’t, after 20 minutes or so, you can do a trial with a hydrochloric acid capsule or two, have them swallow that, and see what it does for the pH.

                                So, we just got a Heidelberg test back two weeks ago; it was fascinating because the patient had this sawtooth pattern, their pH was bobbing up and down throughout the entire test. And it was bobbing up quite a bit, so we knew they had hypochlorhydria, but that sawtooth pattern usually indicates that the pyloric valve isn’t functioning properly and are getting reflux of bile and alkalinity into the stomach. So you see the acidity and alkalinity, it just goes up and down like that.  They gave that patient, I think it was the Wise Woman liquid bitters as a trial during the test. And for 15 to 20 minutes, perfectly calm, there was no up and down at all. It such a great response. You could tell that woman really needs bitters.  It didn’t acidify though, she still had a pH of four, and anything above three is hypochlorhydria. So, she’s going to need something more to get some acidity in there, but it was remarkable what it did for that sawtooth pyloric valve reflux.

Dr. Weitz:            By the way, are herbal bitters best effective at stimulating bile flow, hydrochloric acid, digestive enzymes, or all of the above?

Dr. SSL:               I would say all of the above, and from what I saw last week or two helping with pyloric valve tone as well, it’s just kind of a general tonification for the whole upper GI tract.  And remember, there are bitter taste receptors throughout the entire digestive tract, even in the colon. And you might think, well, that’s ridiculous, why do you need to taste bitter things down there? Well, it turns out they do so much more than just taste bitter, but that’s the first thing that was discovered, so they called them bitter taste receptors, but they do so many important things.  And they’re also found in any tissue, I believe most tissues that change shape, like I think blood vessels have them, and the lungs might have them; bitter taste receptors are present in lots of tissues. So I would say, bitters they might do almost anything, they just help normalize function if they work for the patient.

                            So, they might have hypochlorhydria or achlorhydria, they might have normal acid, they might have excessive acid, and you can check for that if you want to do that. And it’s a great thing to do if your patient has pretty persistent reflux.  Because you want to know if it’s weakly acid or acidic or even neutral or alkaline reflux. And then, you may need to evaluate for the GI flora, especially to check for overgrowth. And you could, I list over some of the tests that can be used over on the side.

                                And I don’t do a lot of testing for H. pylori, but if they have ulcer-like symptoms, severe epigastric pain or a lot of nausea and vomiting, or if they’ve been shown to have ulcers or recurrent gastritis, checking for H. pylori and treating it may be an important thing to do. A lot of H. pylori is just commensal, so I really discourage practitioners from checking for H. pylori unless the patient has ulcer-like symptoms.  Now there are a few other well-proven H. pylori-related diseases, but H. pylori is mostly a commensal organism. It is the most important gastro biome; it’s like the center of the gastro biome. And it’s very important for maturing the immune system in the newborn in the first few years of life.  It’s unfortunate that less than 5% of kids have H. pylori in their stomach nowadays. And that’s why… research shows that there’s increased risk of Crohn’s disease, increase risk of reflux and Barrett’s esophagus. If you don’t have H. pylori in your stomach when you’re a kid, increased risk of food sensitivities, increased risk of the allergic triad, asthma, hay fever, and eczema, and even laryngeal cancer.  The list is kind of crazy how protective H. pylori is, especially for kids in the first five or 10 years of life. It tends to be more problematic in people as they get older, and we’re not exactly sure why, but there’s some virulence factors CagA and CagB and certain others.  By the way, the only lab that checks for those is the GI-MAP stool test. Otherwise, it’s just considered, those virulence factors are considered to be research only.  And I’m not so sure it’s that helpful because knowing which virulence factors they have may not really tell you much, except that if they have significant virulence factors, I think it’s less likely to be commensal and more likely to be pathologic.

Dr. Weitz:            So your recommendation, if we see overgrowth of H. pylori on a GI-MAP stool test, even if there’s virulent factors, unless there’s symptoms indicative of an ulcer, you would tend not to treat.

Dr. SSL:               Yeah, with a caveat. So definitely, I mean, if you find several virulence factors, discuss it with the patient and/or their gastroenterologist and decide if you want to treat it. But-

Dr. Weitz:            How about no virulence factors, but maybe it’s the only thing that’s significantly positive on their stool test, and it’s out of range?

Dr. SSL:               Well, okay. So, if this is a patient… Here’s the thing, I would say always treat H. pylori if you find it, if you know the patient has gastric lymphoma. It’s also called MALToma because mucosa-associated lymphoid tissue is the lymph tissue that has the lymphoma.  Lymphoma of the stomach or MALToma has an incredible response rate to treating H. pylori if the patient has both H. pylori-positive and gastric MALToma.  The tumor literally melts away when you treat the H. pylori. It’s like an 84% success rate. So I would always suggest treating that. [crosstalk 00:21:28]. But If you want to-

Dr. Weitz:            … extremely rare case.

Dr. SSL:                 Yeah. If they don’t have, yeah. And I taught pathology for 17 years, so I’m a who’s who of rare diseases if you want to talk about zebras. But anyway, that’s not what we’re going to talk about.  There are some patients that have chronic iron deficiency, anemia that responds to nothing. And they get treated with IV iron, and well, they feel terrific, and they feel better for about three or four months, and then it all goes away, it drains out, and their ferritin is at eight again, rock bottom.  If they have a positive H. pylori, and you treat that, there was several research studies that showed that within nine months is something like 75% are no longer iron deficient and no longer anemic, and by 12 months after treatment, and they don’t have to take iron, they just treat the H. pylori.  Because the H. pylori steals iron for its own metabolism, and that’s where this comes from. H. pylori can also cause hyperchlorhydria, one form of it. There’s some forms that, well, I don’t want to get into it. But if the H. pylori gastritis is specifically in the antral dominant, then…

PART 3 OF 4 ENDS [01:09:04]

Dr. SSL:                 … antrum, antral-dominant, then that tends to cause hyperchlorhydria. But if it’s pangastritis and it’s affecting the entire stomach lining, it tends to cause hypochlorhydria. So, that hypochlorhydria certainly is a cause of iron deficiency. So, that might be part of the mechanism too.

Dr. Weitz:            One more question on H. pylori, if we see antibodies to H. pylori, doesn’t that mean that we should treat it?

Dr. SSL:                 Well, so there are at least three ways to check for H. pylori, right? There’s the blood antibodies, IgG. There’s stool antigen and there’s the breath test. There’s a H. pylori breath test. The H. pylori breath test and the stool test tell you H. pylori is currently present in the gut. But if you check the blood and you find an elevated antibody, that tells you they’ve had H. pylori at some point in their life, and that’s becoming less and less common, like we said, because of antibiotics and other treatments slowly eroding the levels of H. pylori, and people being treated for H. pylori so they don’t have it. Moms don’t have it to give to their kids.

                                So the question is if you have antibodies, you should treat it. Well, that’s the standard approach. It’s called test and treat, meaning if you find it, you treat it. And that’s why I’m telling you, don’t test everybody for it. Don’t do a stool test that… Like the GI-MAP, it checks everybody for H. pylori, stool antigen. I think it’s actually stool DNA is what they test, which is a unique test. It’s not a standard test. So I would verify it. If you get a positive there, I would verify it with a stool antigen or H. pylori breath test, or even a blood antibody test.  The thing about the blood antibody test is it doesn’t necessarily normalize if you’ve treated H. pylori effectively. It’s not a good follow-up test to see if things have normalized. The stool test and the breath test will normalize if the H. pylori was eradicated, but the antibody may persist. It’s IgG, so it can persist for a long time. So unless you know that they’ve never been treated for H. pylori and there’s some other risk factor, like iron deficiency anemia that’s not responding to anything or ulcers that keep recurring or chronic gastritis. I just say think about it before you treat it. [Crosstalk 01:12:03] But the standard approach is test and treat. So if you test, you’re expected to treat. So don’t test everybody.

Dr. Weitz:            And your favorite treatment, do you use the triple antibiotic therapy or do you use a mastic gum? Do you use…

Dr. SSL:                 I never treat it anymore-

Dr. Weitz:            Oh, okay.

Dr. SSL:                 … because ever since 1995, every MD and osteopath, everybody treats it whenever they find it on a test. So it’s very rare. The only cases I usually see now are people who have… Most of the patients I see have already been to at least one, if not two or three gastroenterologists already. So, that’s been picked off. But I’ll tell you, if I were going to treat a patient for H. pylori, I would use triple therapy, and I would for 10 to 14 days nowadays, it used to be seven. And I would add lactoferrin, at least 300 milligrams, three times a day during the treatment because that increases the effectiveness.

                                I would add a biofilm disruptor. The simplest one, of course, being NAC. And there’ve been several studies showing that antibiotic-resistant H. pylori, when you add NAC to break down the biofilm, you get a much higher response rate. So I do those things and I add a probiotic because probiotics together with triple therapy have been found to increase the success rate. So if you’re going to give them two antibiotics plus a proton-pump inhibitor, give them these three extra things which can really improve the effectiveness.

                                I think I made one more slide because I wanted to make sure everybody knows about Cut Out the Crap. This is a handout. I have a GERD handout that I give to all my patients that have reflux to remind them the things that are commonly triggers and causes. So these are the things I want them to do trials with if they’re using these things, or these are things that are going on in their life. So C stands for coffee, caffeine in general, so you could include energy drinks and things, cigarettes and chocolate. So methylxanthines in general, but especially chocolate and caffeine and smoking.

                                Then, we say a number of mechanisms by which tobacco smoking can affect reflux, and perhaps even a patch or chewing tobacco as well. Chewing tobacco, of course, is horrible for cancer of the mouth. And so they can do trials removing these things. And if it turns out coffee, without coffee they don’t have any reflux, you can have them do a trial with low acid coffee. There are several brands. One is called Tylers brand that are sold in some stores. They reduced the amount of acid in it, and that can really help people with reflux be able to drink some coffee if they really like coffee.

Dr. Weitz:            What was that about chewing gum causing cancer in the mouth?

Dr. SSL:               Not chewing gum, chewing tobacco.

Dr. Weitz:            Oh, chewing tobacco. Okay.

Dr. SSL:               As a cause of leukoplakia and erythroplakia.

Dr. Weitz:            Oh, okay. Yep. Yep.

Dr. SSL:               R stands for refined carbohydrates. This comes from Sherry Rogers’ book, No More Heartburn, but I added some things. I reworked it a little bit. So refined carbohydrates, but also any carbohydrates. So we find that low fermentation diets, like Fast Tract Diet and SIBO type diets and Cedar-Sinai diet and FODMAPs diet sometimes are remarkably effective at treating reflux just by themselves, just by reducing the total amount of carbohydrate, fermentable carbohydrate per meal. I put Rx in there for drugs because there’s a whole… I have a slide when I do my full lecture on reflux, that all the drugs on the left that can irritate the esophagus and cause erosive esophagitis, and all the drugs on the right that can trigger more reflux in a patient who already has reflux, often things that are anti-spasmodic and relaxed the lower esophageal sphincter or delayed gastric emptying.

                            And then R is for rapid eating, Fletcherizing, chewing food until it’s liquid, taking your time in a relaxed manner, that can totally cure your patient’s reflux, a lot of your patients. It also tends to promote parasympathetic tone. So you’re going to have more vagal tone. You’re going to have more improved digestion on many, many levels. So please don’t forget that if your patient is a shoveler, if they eat their meals in five minutes, if they eat at their desk while they’re doing work on their computer and they don’t even know that they’re finished because they ate so fast, you got to work with that. That’s really important.

Dr. Weitz:            By the way, do you have any tricks to helping patients improve at that?

Dr. SSL:               Well, I got to put in a plug. My wife is a neurofeedback practitioner, biofeedback practitioner and a stress coach, stress management coach. She recently wrote a series of six blog articles that I would highly recommend everybody read on our website, hmmpdx.com, which is on there, Hive Mind Medicine website. You go to our blog page and she wrote six blogs. One of them is specifically on chewing and why that’s so important. I didn’t even know about this until I read her article that the trigeminal nerve, which controls mastication in large part, actually when the brain perceives through the trigeminal nerve that you’re chewing your food and taking your time and thoroughly chewing, it sends a message to the brainstem that calms the autonomic nervous system and turns on the parasympathetics. So, yeah, it’s so great the stuff that she writes, so I just highly recommend. It’s free and it’s on our website. You can recommend it to your patients to read them. Just really cool.

Dr. Weitz:            Thanks.

Dr. SSL:               And A in crap, A is for acidic foods because some people if they cut out tomatoes and nightshades especially, especially tomatoes. Personally, it’s white potatoes for me. It’s that nightshade. That’s the only food that gives me reflux. I don’t ever have reflux now because I just don’t eat white potatoes. So you know what, food allergies can be a thing. That’s why I have allergenic foods there. If someone’s sensitive or allergic to a food, that could be a big trigger for reflux.

Dr. Weitz:            By the way, do you have a favorite food sensitivity test?

Dr. SSL:               I hardly ever do food sensitivity testing. I used to do a lot of it. I actually worked at a lab that did cytotoxic leukocyte testing, and I would see those patients and go over their lab results. But because so many of my patients have bacterial overgrowth now and I’m putting them on specific carbohydrate diet or Dr. Siebecker’s SIBO Specific Food Guide, which is related to the specific carbohydrate diet, I use that as an elimination diet initially and see how much better they get. A lot of times their reflux goes away just when they’re on that diet, and it’s part of our treatment for bacterial overgrowth, a low fermentation diet. So I don’t do a lot of that food sensitivity testing, but a lot of my patients come having already had those tests so I don’t have to do it because they already had one recently and that’s really helpful.

                            And I mentioned apple fat pregnancy or apple fat increasing intra-abdominal pressure, not that it’s easy to get rid of that. Apple fat is a major cause of insulin sensitivity, and that’s where the adrenals come in with treating someone’s either bacterial overgrowth or reflux because I find that adrenal maladaption with especially high cortisol and low DHEA, that ratio being off really can promote insulin resistance and cause people to accumulate fat, visceral fat around the waist, which triggers more reflux.

                                P is for pop or soda pop because soda seems to be a big one for some people. Peppermint, oops, sorry, peppermint, because it’s a smooth muscle relaxant probably, really strong peppermint. After-dinner mints can be just murder for some people with reflux. Altoids, curiously strong menthol. Even though it’s great for people with cramps, abdominal cramps, sometimes enteric-coated peppermint can be a terrific, smooth muscle relaxant and it’s the only smooth muscle relaxant that doesn’t promote bacterial overgrowth. It actually can treat, be part of the treatment for hydrogen SIBO, but it can relax the lower esophageal sphincter for some people. So, it’s something to consider. This is one I added in also, packing in food at bedtime, right? So you really want them to finish eating at least three hours and don’t have a huge meal at dinner time. Eat breakfast like a king, lunch like a prince, and dinner like a pauper, or a queen and a princess and a pauper or they, depending on your approach.

Dr. Weitz:            It’s interesting that one of the current trends in functional medicine is intermittent fasting. And the way that most people do it is they skip breakfast, so they end up eating a bigger dinner because of it.

Dr. SSL:               Yeah. I mean, that can work for a lot of people, certainly having a light dinner at least three hours before you go to bed. And then if you want to eat breakfast later, that’s probably a better way for some people. You’re right. And then the last one is progesterone. Most women don’t produce too much progesterone, but they might be taking a higher doses of progesterone, like 200 milligrams or higher. We know progesterone is a smooth muscle relaxant. So that could at least theoretically be a problem for some women. I don’t see it very often, but it’s certainly a problem in pregnancy because progesterone levels go sky high in pregnancy, that’s a normal pregnancy, women that aren’t prone to miscarriage. So, that’s the Cut Out the Crap. You will become a reflux treating genius to your patients. So if you just really pay attention to this and have them go through whatever they’re doing and do a trial without it, this could really… If I said nothing else tonight, this is gold. It’s crap, but it’s gold.

Dr. Weitz:            If you have a patient with high acid and they have reflux, are there specific products that you like to use? Besides working for the underlying causes, like SIBO and food sensitivities and these other things, are there certain nutritional products that you like to use as part of the treatment that could at least help symptomatically on a short term?

Dr. SSL:               Well, certainly all the demulcents can be helpful and worth trying, whether it’s slippery elm or marshmallow root or DGL. Slippery elm gruel is a really nice one. Just mixing the powder with enough water to make a paste and taking up to four tablespoons of that, it can just be remarkably relieving within minutes. I would also say if you’re not a homeopath, consider the remedy nux vomica if it fits a few other things for your patient besides their severe reflux, especially in people who have tended to overdo it, like people who drink too much alcohol, take too many drugs, overeat, overdo everything, and people that overwork, workaholics. If they have severe reflux, nux vomica as a homeopathic remedy can really be the end of their reflux. So, that’s another one to consider besides the demulcents.  I have to say that if your patient has LPR that we talked about, a lot of patients with laryngopharyngeal reflux that reflux up here, they will wake up. You’ll think they have PTSD because they’ll wake out of sleep gasping for breath, or you think they have asthma or something. And it turns out it’s just that their vocal cords and their pharynx are swollen and edematous from the reflux. Especially when they’re lying down at night, they’re more likely to have reflux up into their throat.

                                Some of those patients, I’ll pick the lowest dose of famotidine, which is over the counter. Before proton-pump inhibitors, there was Tagamet and other drugs that are called H2 receptor antagonists. I mean, if you’re waking up feeling like you’re dying and you can’t sleep because you’re scared if you go to sleep, you will stop breathing, I mean, these people end up in terrible shape. So if you know they have LPR, if you need to, you may want to have them on famotidine, at least until you figure out something else to deal with the cause of their reflux.

Dr. Weitz:            Yeah. I sometimes will use a product from Gaia Herbs called Reflux Relief, and I have to chew two of those. Really, really nice product to help [crosstalk 00:19:12].

Dr. SSL:               For LPR or just for reflux in general?

Dr. Weitz:            Just for the reflux. Yeah.

Dr. SSL:               There’s a newer product called Heartburn… Oh, I always forget the names of these things. Heartburn Advantage. It’s made by Integrative Therapeutics, and it’s a combination of herbal prokinetics, so especially if your patient has delayed gastric emptying, if they have type two or type one diabetes, or even pre-diabetes or some other cause of delayed gastric emptying. So it has herbal prokinetics and it has some demulcents. I think, DGL in there as well. And so that may be really helpful as well. Some promotility and some demulcent activity.

Dr. Weitz:            Have you ever used Pepto-Bismol?

Dr. SSL:                 Yeah, I use almost everything when I have to. Yeah. Bismuth, that’s over-the-counter Bismuth. Except for the flavor and the artificial sugar that might be in there, you can just have people get, if they’re going to take it for any length of time, bismuth subsalicylate or bismuth subnitrate. And especially if they’re salicylate sensitive, if they have nasal polyps or asthma and they’re aspirin sensitive, then you’d want to use the bismuth subnitrate. But that can sometimes be really healing for ulcers and erosions and reflux. So, it’s just another demulcent.

Dr. Weitz:            Cool. Well, this was an incredible discussion, Dr. SSL. Lots of clinical pearls.

Dr. SSL:               Yeah, it’s dangerous to start asking me questions about things that I love to talk about. By the way, I’m writing. I’m taking two weeks off the end of the year to finally finish my book on reflux.

Dr. Weitz:            Oh, cool.

Dr. SSL:               We’ll make an announcement on our website about it, but it’s called Getting Real About Reflux, and it’ll cover all these things and more details. I’m trying to make it a book that laypeople can read, your patients can read, as well as doctors can learn a ton from. I’ve never written a book like that before so it’s taken me a little longer than just writing for doctors. But yeah, I’m going to take some time off and really try to get it done. I hope we’ll have it done going through the editing phase by summer. So, that’s coming up.

Dr. Weitz:            Okay. Awesome. Awesome. Thank you so much. Thank you everybody for joining us, and happy holidays. We’ll see you in 2021.