All about acid reflux or GERD (gastroesophageal reflux disease)

At the time of this post, I am currently pregnant and dealing with terrible acid reflux. Honestly, I had no idea how severely it can affect people's quality of life until I experienced it myself. It's a lot better now, for the most part, so I thought, why not share the strategies that worked for me with all of you?

Can a pelvic health physio treat acid reflux? 

Isn't this something that GI doctors or dietitians should be concerned with? You would be surprised to know that acid reflux is one of the conditions I see in my practice. Many of my pregnant clients, people with hypermobility or EDS, people with constipation/IBS, etc., often have acid reflux as one of their symptoms along with other gut-related or pelvic floor issues. So, let's begin by understanding what acid reflux is exactly and what causes it.

What is acid reflux or GERD (gastroesophageal reflux disease)?

As most of you must be familiar with, acid reflux or GERD (gastroesophageal reflux disease) happens when the gastric contents regurgitate back into the food pipe. The gastroesophageal junction (where the food pipe enters the stomach) has a valve called the cardiac sphincter or lower esophageal sphincter (LES) that usually checks any backflow of stomach contents. As we know, the stomach contents are highly acidic. This backflow, if it continues for a long time, can erode the mucus membrane of the food pipe, creating inflammation in the area called esophagitis, and can be extremely painful.

Some of the common symptoms of acid reflux:

• Burning sensation in the chest
• A feeling of a lump sitting in the throat
• Nausea

Other atypical symptoms that aren't quickly seen as acid reflux:

• Chest pain
• Difficulty swallowing
• Asthma
• Chronic cough
• Laryngitis

Gastroesophageal is usually controlled by:

• The smooth muscular contraction of the LES (internal sphincter)
• And the crural portion of the diaphragm (external sphincter). This is where the food pipe enters the stomach, called esophageal hiatus.

Of course, the diaphragm has a role here too!! It's not one of the most special muscles in our bodies for no reason ;)

The LES needs to relax as the food is coming down the food pipe to allow it to enter the stomach. It then needs to contract, along with the diaphragm, to prevent the backflow of the stomach acid in response to an increase in intra-abdominal pressure (IAP).

Mechanisms involved in the development of GERD

1. Motor impairment
   1. Impaired resting tone of LES: At rest, LES pressure should be 15-30 mmHg higher than the intra-stomach pressure. Certain hormones (progesterone in pregnancy), certain medications (Calcium channel blockers), certain foods (high fat, chocolates), and habits like smoking and alcohol intake can reduce the resting tone of LES.
   2. Transient LES relaxation: This is the untimely relaxation of LES, which otherwise works normally, usually seen after meals or during sleep. Again, smoking, alcohol, and certain foods can increase the frequency of such episodes.
   3. Delayed gastric emptying: commonly seen in people with reduced gut motility, such as EDS (Ehlers Danlos Syndrome) and pregnancy.
2. Hiatal Hernia- it's the bulging of the upper part of the stomach or other abdominal organs through a hiatus/opening (this is where the food pipe passes through) in the diaphragm. The herniated part of the stomach can create a pocket of acid in the esophagus, which can continue to irritate the mucosal lining, creating inflammation. Increased intra-abdominal pressure and muscular weakness are usually one of the culprits.
3. Visceral Hypersensitivity- some people are more sensitive in this area despite having normal resting tone and pressure of LES. This most likely results from impaired sensory processing or an unregulated nervous system.
4. Impaired mucosal resistance and impaired esophageal acid clearance are other mechanisms through which people can experience acid reflux.

As I mentioned before, at rest, LES maintains a higher pressure compared to the stomach by 15-30 mmHg. A minority of patients have a consistently weakened pressure of LES. This is common in pregnancy and EDS/Hypermobility.

In pregnancy, increased levels of the hormones estrogen and progesterone relax the smooth muscles of the LES, lowering the pressure. On the other hand, as the pregnancy progresses, the IAP also increases, which can further make reflux worse.

In EDS/ generalized Hypermobility - The issue is with the connective tissue, which can affect the functioning of the smooth muscle of the gut. This impairs the smooth muscle contraction of the LES and delays gastric emptying, which can further worsen the reflux.

So what can you do?

As often believed, acid reflux is not caused by increased acid production. Therefore, most interventions that neutralize or reduce the acid production are, at best, masking the symptoms as the reflux is not reversed. Medications such as PPI are great for a short duration but can impact the gut/overall health if taken for an extended period.

Some of the lifestyle changes that you can incorporate to reduce the severity of symptoms are:

• Identify triggering foods - usually caffeine, alcohol, fatty foods
• Manage stress and watch for food-related anxiety as well. Managing diet could be a great way to control the symptoms for some people. However, the hypervigilance around food can sometimes backfire too. Discuss this with a registered dietitian, as food is not always a trigger. This is what I have personally experienced as well. So, I try not to restrict my diet.
• Do not wear anything tight around the waist, especially while eating. Even tight bras, especially the wired ones, can impact your diaphragm's ability to function well & can add to the increased intraabdominal pressure.
• Do not eat your food in a slumped position, as it reduces the diaphragm's ability to function correctly.
• Practice diaphragmatic breathing for 5-10 minutes before eating (and after if need be), and chew your food well to an apple sauce consistency. This will also slow down your eating, which will help slow gastric emptying in case you have it.
• Strengthen your diaphragm- Diaphragmatic exercises can improve symptoms of GERD. Check out these examples. 

(Note: do not attempt the position where you are lying with your head down and legs up when experiencing reflux).

• Improve Rib cage mobility - if your rib cage is not flexible, it will affect your diaphragm's ability to move well. Therefore, exercises to improve overall thoracic spine and rib cage mobility can significantly improve GERD symptoms. Check out these exercises here and here. 
• Do not lie down after eating, as it can worsen the symptoms. Keep the head up at 45 degrees, at least.
• Movement is a great way to help with gut motility, which can improve acid reflux by improving gastric emptying.
• Clenching or sucking in your belly could also impair the diaphragm's functioning and can also increase the IAP. Both have the potential to make GERD worse.

Personally, eating smaller meals, diaphragmatic breathing, and not wearing restrictive clothing hugely improved my symptoms. Not worrying constantly and being hypervigilant about the food I eat has also helped me tremendously.

References:

Altuwaijri M. Evidence-based treatment recommendations for gastroesophageal reflux disease during pregnancy: A review. Medicine (Baltimore). 2022 Sep 2;101(35):e30487. doi: 10.1097/MD.0000000000030487. PMID: 36107559; PMCID: PMC9439837.

De Giorgi F, Palmiero M, Esposito I, Mosca F, Cuomo R. Pathophysiology of gastro-oesophageal reflux disease. Acta Otorhinolaryngol Ital. 2006 Oct;26(5):241-6. PMID: 17345925; PMCID: PMC2639970.

Halland M, Bharucha AE, Crowell MD, Ravi K, Katzka DA. Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial. Am J Gastroenterol. 2021 Jan 1;116(1):86-94. doi: 10.14309/ajg.0000000000000913. PMID: 33009052.

Jaynes M, Kumar AB. The risks of long-term use of proton pump inhibitors: a critical review. Ther Adv Drug Saf. 2018 Nov 19;10:2042098618809927. doi: 10.1177/2042098618809927. PMID: 31019676; PMCID: PMC6463334.

Siboni S, Bonavina L, Rogers BD, Egan C, Savarino E, Gyawali CP, DeMeester TR. Effect of Increased Intra-abdominal Pressure on the Esophagogastric Junction: A Systematic Review. J Clin Gastroenterol. 2022 Nov-Dec 01;56(10):821-830. doi: 10.1097/MCG.0000000000001756. Epub 2022 Sep 7. PMID: 36084164; PMCID: PMC9553247.

Zeitoun JD, Lefèvre JH, de Parades V, Séjourné C, Sobhani I, Coffin B, Hamonet C. Functional digestive symptoms and quality of life in patients with Ehlers-Danlos syndromes: results of a national cohort study on 134 patients. PLoS One. 2013 Nov 22;8(11):e80321. doi: 10.1371/journal.pone.0080321. PMID: 24278273; PMCID: PMC3838387.