> Health and Disease > Gastrointestinal > gastroesophageal reflux disease (GERD)

Pamela is bitter about her past experience with a gastroenterologist. “I have this mysterious gastrointestinal problem that was never diagnosed. I can’t eat anything with flavour, and I get acid from even completely bland food. I take antacids every day but still have symptoms of acid. Doctors can’t find anything.”

Pamela’s bowel specialist finally performed an endoscopic procedure. “They put this thing up my nose and down into my esophagus and they measured the amount of acid. The doctor said there was a tiny bit of acid but not enough to explain the pain I’m having.”

Pamela is experiencing gastroesophageal reflux disease, or GERD, the distressing chronic disorder in which stomach acid flows upward into the esophagus, or swallowing tube. The specialist’s mistake was in dismissing Pamela’s pain based on what he saw in the esophagus. Research now shows that GERD originates as much in the nervous system as it does in the intestinal tract. People can legitimately experience pain without dramatic findings on X-rays or scope procedures.

Hypersensitive to Pain

A 1992 study found that, despite no increase in the amount of acid present in their esophagus, subjects diagnosed with GERD suffered more heartburn during stressful stimuli. Why? Stress, it appears, lowered their pain threshold–the point at which their brain would interpret acid irritation as painful.

In brain scans of people with intestinal tract pain, the part of the cerebral cortex reacting to painful stimuli was shown to be overactive as compared with “normal” subjects, even in anticipation of painful stimuli. These people weren’t malingering or hysterical: their brain centres were genuinely hypersensitized to perceptions of pain. To describe such patients with an “It’s all in their head” kind of comment may be correct anatomically, but not with the pejorative dismissal that phrase usually implies.

People with GERD may in fact experience more frequent reflux than other people. Once more, it is a brain-gut problem. Investigators comparing healthy controls with reflux patients found that the resting pressure of the esophageal sphincter–the band of muscle meant to kept stomach acid from flowing upward–was more frequently low in GERD subjects. The decreased efficiency of the sphincter permitted more episodes of reflux.

How do the mind and brain contribute to reflux? It happens by means of the vagus nerve, which is responsible for muscle tone in the lower esophageal sphincter. The vagus receives messages directly from the brain and is very much influenced by emotional factors. Stress reduces the tightness of this muscle, facilitating reflux. It is well known that stress can also increase the production of stomach acid.

Treat the Root Cause

The treatment people with GERD receive usually begins with advice about diet - for example, avoiding substances that would relax the esophageal sphincter or raise acid levels, including nicotine, caffeine, alcohol, spicy foods, and heavy fats.

Often GERD sufferers are also prescribed antacids or heavy-duty medications that either lower acid secretion or regulate the contractions of the sphincter muscles. Such medications are meant to be taken for relatively short periods of time but many people become dependent on them, as Pamela has. “I’ve been on Pantaloc for years. It’s supposed to wipe out acid production and I was only supposed to take it for six weeks,” she says. “But every time I stop, the pain returns.”

Pharmacological treatment makes physiological sense, in the short term, and dietary advice is prudent. The problem is that neither addresses the long-term issue of what caused the stress-induced reflux and the heightened pain perception in the first place.

Untie Emotional Knots

My clinical experience, in keeping with the scientific literature, shows that GERD originates in chronic stresses and unresolved emotional issues. These stresses and emotional knots disorganize both acid production and the normal contraction patterns of the esophageal muscles.

Pamela’s example illustrates this point, with her history of an unhappy childhood and lifelong emotional frustrations. None of the physicians she had seen in her long odyssey of help-seeking had ever suggested that she examine the stresses she experienced or how she dealt with her many feelings of unhappiness and suppressed anger.

To address GERD holistically we need to look at the whole person, not just the gastrointestinal tract. Like all medical conditions, GERD happens not to individual organs but to people whose minds and bodies form one unit. We need to consider the entire life experience, past and present, and deal with life stresses if we are to become symptom-free.

Gabor Maté, MD, is a Vancouver physician and author of the best-selling When The Body Says No: The Cost of Hidden Stress (Vintage Canada, 2004).

Source: alive #268, February 2005