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Treating GERD

I was mentioning this morning about restricting test to ones that are going to change your treatment plan or ones that help out when you are unsure or it will save the patient's life. I never ordered CT scans for kids that had mild concussions,regardless of how the parents pleaded. I always ordered a CT with a stroke to see if it was ischemic or hemorrhagic.

When I was with Jonathan Wright,we frequently measured stomach pH using the Heidleberg test. Usually,what we would find is that the person had GERD not because they were producing too much hydrochloric acid(HCl),but too little. I would have them add HCl and no more GERD-overnite! However, once I started noting this was the normal case, I stopped ordering the test and just gave them a trial of HCl.
Always playing the Devil's advocate,I questioned why if low acid was the problem did acid proton pump inhibitors, alkalinizing agents,and H2 blockers work? No one had an answer. Its not critical to treating but you really don't master the morbidity until you understand the pathophysiology. What I discovered made so much sense.
GERD is due to excess acid. The acid burden is cumulative. Part of the burden does come from gastric parietal cell production of HCl. But that is normal. Even so,by reducing this part of the total acid burden using a PPI,you can sometimes relive symptoms-transiently. Antacids neutralize the total acid burden; the other component of which is metabolic acids from native microbe overgrowth. H.pylori can be one of these microbes. H.pylori is a normal constituent of human microbiota. Its not an infection. Its an overgrowth. An infection may mean you need to use an antimicrobial. Tuberculosis is an infection. An overgrowth tells you you have an imbalance that is conducive to native microbial overgrowth.
What normally keeps the microbiota in balance in the GI tract? One element is production of HCl. The stomach is a 2 hour holding tank for your meal. Without sterilization, food left in your stomach or on your kitchen counter will start to attract microbes. Most likely, your GI tract has many more microbes than your kitchen counter. If you are not producing enough HCl,you will be vulnerable to overgrowth of native microbes. The metabolic waste products of microbes,and human cells for that matter,are various acids. If you supplement with HCl, you bring microbiota overgrowth back into ecological balance and,  therefore also reduce the total acid load. The benefit of using supplemental HCl is that HCl is also critical for the absorption of a wide range of nutrients-amino acids,vitamins and minerals. You don't improve nutrient absorption with Prilosec or Tums.
The other component that normally keeps microbiota under control is the population of so called "good bacteria". This population can be decimated by overuse of antibiotics,chlorinated water, and radiation. Even if "good bacteria" are not decimated,factors such as diet choices(too much sugar/grains/animal protein) can be conducive to overgrowth of native microbiota that cause symptoms such as GERD,colitis,colic,and excess intestinal gas. Adding a probiotic makes sense when treating GERD.
Another condition that should be investigated if GERD presents is hypothyroidism. Hypothyroidism,in general,creates an environment conducive to overgrowth of Candida and other microbes. Fungal overgrowth opens the door for overgrowth of other microbes(This is what happens in sinus infections). Ecological balance depends on the body being able to maintain a temperature of 98.6. In areas where the temperature is lower,cells will not do well. This will invite scavengers just as it does on the African plains or any other ecosystem.
In babies and children, I normally recommend starting with probiotics and iodine supplementation. Assess if the mom was over age 25 when she was pregnant or if the baby was over 8 lbs at birth or had jaundice. These are red flags for hypothyroidism. This may or may not correct with age. Apple cider vinegar can be used in the pedi population instead of HCl.
 
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