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Dr. Myhill’s counter-intuitive explanation for why heartburn is such a common problem (and why Dr. Paul Cheney considers it a particular problem for Fibromyalgia and ME/CFS patients)

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By Sarah Myhill, MD* • • November 2, 2007

Heartburn (Gastro Esophageal Reflux Disease, or GERD) In this condition, the patient experiences pain behind the breast bone, particularly after eating, as a result of the acid contents of the stomach refluxing into the esophagus. There is no doubt there has been a great increase in this condition, resulting in a great many patients having to take acid blockers such as LosecR [in the UK and Canada, PrilosecR in the U.S.] to control this symptom. Excessive acid in the stomach can be caused by Helicobacter-Pylori infection, but I have now heard from two Consultant Gastroenterologists that if they discover H-Pylori in the stomach they do not use eradication therapy because it does not seem to help the gastro esophogeal reflux. For some time I have pondered over the explanation for this because it did not really seem to make sense, but I think now I have a possible answer. The normal esophagus is neutral at pH 7 [pH is a measure of a solution’s acidity or alkalinity; pH 7 is neutral, lower values are more acidic, and higher values more alkaline]. Normal stomach contents is extremely acid at say pH 2, the normal duodenum is alkaline at pH 8. As foods are eaten and enter the stomach the effect of the food arriving dilutes stomach contents, and the acidity rises: The stomach pours in acid to allow digestion of proteins to take place and the pH falls back down to its normal value of 2. The key to understanding GERD is the pyloric sphincter, which is the muscle which controls emptying of the stomach into the duodenum (first part of the small intestine). This muscle is acid sensitive - and it only relaxes when the acidity of the stomach is correct - i.e., pH 2. At this point stomach contents can pass into the duodenum (where they are neutralized by bicarbonate released in dribs and drabs from the bile ducts). If the stomach does not produce enough acid and the pH is only say 5, then the muscle which allows the stomach to empty (the pyloric sphincter) will not open up (dilate). When the stomach contracts in order to move food into the duodenum, the progress of the food is blocked by this contracted pyloric sphincter. But of course the pressure in the stomach increases and the food gets squirted back up into the esophagus. Although this food is not very acid (not acid enough to relax the pyloric sphincter), it is certainly acid enough to burn the esophagus, and so one gets the symptoms of gastro-esophageal reflux. The paradox is that this symptom is caused by not enough stomach acid! That is, the reverse of what is generally believed! Antacid Doesn't Cure... Of course, the symptoms can be totally alleviated by blocking stomach acid production completely. This is why drugs that inhibit secretion of stomach acid such as GavisconR, ZantacR (H2 - histamine - blockers) and LosecR (proton pump inhibitors) work. It also explains why eradicating H-pylori does not help in GERD. Eradication of H. pylori has the effect of reducing stomach acidity, not increasing it! Use of drugs, therefore, whilst they may relieve the symptoms in the short term, usually means that the patient has to take these drugs regularly in the long term in order to prevent the symptom from recurring. This may be excellent news for drug company profits, but I am concerned about the long term blockage of stomach acid production. # First of all, stomach acid is highly necessary for the effective digestion of proteins. It may well be that if proteins are not digested this could have adverse effects lower down in the gut as well as the problems of protein malabsorption. # The second point is that the acid stomach kills bacteria in food, and the upper part of the gut - the small intestine - is meant to be sterile. If this acid production is blocked, then one can expect to get bacterial and possibly yeast overgrowth of the upper gut and this may also have long term problems. For example in Japan where hypochlorhydria (low stomach acid) is extremely common, there is the highest incidence of stomach cancer in the world. Therefore, the worst thing in the long term that one can do for this condition is block acid production, because this makes one more likely to get GERD. ... But Acid Might! Actually, I think the answer is to give patients more acid in order to allow the pyloric sphincter to open properly and prevent reflux. The problem with this intervention is that initially the symptoms of GERD will be made much worse, but my view is that in the long term the symptom will be improved…. The treatment is to: # Take betaine hydrochloride [betaine HCL, which is hydrochloric acid - stomach acid - derived from beets] with food in order to make stomach contents as acid as possible so that the pyloric sphincter will work properly. # Small meals will also help, so that the stomach finds it easier to become acid. # Furthermore, do not dilute that acid by drinking a lot of fluid with a meal. # It may be worth using a medicine which coats the esophagus, such as De-NolTM or one of the herbal preparations such as Mastica which has no effect on stomach acidity. # A further possibility would be to try one of the drugs which helps relax the pyloric sphincter, such as metoclopramide. GERD and Allergy Finally, it should always be borne in mind that GERD can certainly be caused by allergy, and if I had a patient who also had other symptoms such as headache and irritable bowel syndrome, then it would be well worth trying an elimination diet. * * * * Dr. Paul Cheney’s View on Betaine HCL for ME/CFS Patients The potential need for supplementary betaine HCL is particularly relevant for the majority of ME/CFS and FM patients, according to Dr. Paul Cheney, MD, PhD. Also, there is a very simple preliminary test for insufficient stomach acid that you can do at home before consulting your doctor, as well as a simple way to tell after one dose if further B-CHL supplementation is not advisable. For details, see # “Acid Stomach – or Not Enough Stomach Acid? The Symptoms Are Similar, but for CFS and FMS Patients It’s Often the Latter,” and # “Dr. Paul Cheney on Betaine for Chronic Fatigue Syndrome and Fibromyalgia Patients.” ___ * Dr. Sarah Myhill, MD, is a UK-based physician focused on preventive medicine with a special interest in ME/CFS and FMS. This article is reproduced with permission from Dr. Myhill’s patient-information website ( ) R Sarah Myhill Limited, Registered in England and Wales: Reg. No. 4545198. See also Dr. Myhill’s free 179-page online book – Diagnosing and Treating Chronic Fatigue Syndrome Note: This information has not been evaluated by the FDA and is not meant to prevent, diagnose, treat, or cure any illness, condition, or disease. It is essential that you make no decision about additions to or changes in your health support plan or regimen without first researching and discussing it in collaboration with your professional healthcare team.

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