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Heartburn and Stress



Today I want to discuss the connection between stress and gut symptoms with a focus on heartburn. The truth is both acute (emergency) and chronic (overtime) stress significantly impact our bodies, minds and spirits. Then I am going to talk about what exactly is heartburn with a quick anatomy and physiology lesson to discuss the connection between the nervous system, specifically the vagus nerve and your gut!


What is stress?

Hans Seyle, MD was an endocrinologist and the founder of stress research. He defines stress as “an acute threat to homeostasis,” or the balanced state, whether it is “physiological (real) or perceived (psychological).” An example of a real threat is being attacked while a perceived threat is watching someone on TV being attacked. Chronic stress is daily, perhaps even multiple times throughout the day.


Anything that stimulates your body’s physiology to be in a state of increased arousal and may include the following symptoms increased heart rate, sweating, increased breathing rate, muscle tension and emotional tension such as more prone to outbursts or ability to ‘deal with life’ becomes slightly more difficult.


Stress may also be environmental like pollution or emotional and mental stress like that associated with financial troubles or family conflict.


What is heartburn?

Aka acid reflux, indigestion, GERD, LPR/silent reflux, dyspepsia


Symptoms may include: coughing, wheezing, hoarseness, sensation as if something is stuck in the throat, the need to clear throat especially after eating or drinking, post nasal drip, yellow coating on tongue, acidic taste in mouth, regurgitating after eating, non-cardiac chest pain, burning in throat/mouth, early fullness and stomach pain.


Usually it is not life threatening, but a complete medical work up should be completed to ensure it is nothing more serious.


I have noticed that a lot more people may suffer from heartburn and simply not realize it because they experience post nasal drip or throat clearing as their own symptoms. A prominent ENT doctor has also noticed this and refers to this as silent reflux.


Anatomy and Physiology of the esophagus, stomach and first part of the small intestines

Anatomy of the esophagus, stomach, lower esophageal sphincter and the pyloric sphincter in humans

This image shows the lower esophageal sphincter and the pyloric sphincter in relationship to the stomach and the duodenum both of which are innervated by the Vagus nerve, which is discussed below.



LES and pyloric sphincter innervation and physiology


There is a lot going on in the above image. My goal was to help you understand the innervation or which nerves affect the stomach, the lower esophageal sphincter (LES) and the pyloric sphincter. When you are in rest and digest mode, or the activation of the parasympathetic nervous system, this stimulates the Vagus nerve which allows digestion of meals to take place most effectively.


Digestion Physiology

Digestion begins with the aroma of cooking foods. Then chewing and tasting food produces saliva to breakdown simple carbohydrates. Once a person swallows the food, it travels into the stomach where acid begins to break down proteins and complex carbohydrates. After that the food bolus, or chyme, enters the duodenum and is mixed with bile and pancreatic juices to emulsify fats, absorb various nutrients and neutralize the stomach acid in the chyme. Lastly the chyme migrates through to the large intestines, or colon, to absorb mostly water and a few final nutrients before excreted as feces.


Sympathetic stimulation causing constriction and decreased blood flow to help you run from the “tiger.” Stressful events INITIALLY increase HCl secretion but chronic or prolonged stress such as daily triggering by the news (or other consumed media) leads to decreased stomach acid production aka hypochloridria which is worsened by the use of suppressive medications. Low stomach is a very common cause of heartburn.


Commonly used medications that suppression symptoms of heartburn

There are three classes of medications that are commonly referred to as antacids: H2 blockers like Zantac and Pepcid, calcium carbonate like Tums and Maalox and proton-pump inhibitors (PPIs) like Prevacid, Prilosec and Nexium.

PPIs

  • PPIs directly blocks acid production.

  • Currently the FDA has recalled all the PPIs on the market for containing higher than reported amounts of a cancer-causing agent called N-nitrosodimethylamine (NDMA). These products are still on the shelf.

  • Associated with B12 and magnesium deficiencies

  • Associated with rebound reflux, meaning a significant worsening of heartburn symptoms when you try to get off these medications

H2 blockers

  • H2 blockers inhibits the messenger that stimulates the production of stomach acid.

  • Zantac has also been recalled for the same reason as the PPIs

Other antacids such as Tums, Maalox and Mylanta

  • These tablets are made up of either magnesium or calcium and may contain aluminum and are used to soak up ‘extra’ stomach acid to neutralize the acid reflu

  • All three of these medication classes are meant to be taken short-term (less than two weeks) or for occasional heartburn. Long-term side effects may include nutrient deficiencies, poor digestion and worsening of symptoms or miss diagnosing a more serious condition.


Stress and heartburn


This image is from the 2011 review by Konturek et al.


Stress affects many aspects of our gastrointestinal system including gut motility or the speed in which you guts are able to digest and absorb water and nutrients. Stress affects the secretions throughout the GI tract – if you recall initially increases them but over prolonged periods of stress these secretions all decrease.


Stress affects the microbiota, or the microbiome, when we are “stressed” we create a terrain that is more conducive to supporting organisms that are more virulent (bad guys). Often these organisms will increase the production of certain neurotransmitters such as norepinephrine (NE) and epinephrine (E) aka adrenaline and increasing the pro-inflammatory cascades in our body. Both NE and E are associated with increased pain sensitivity and increased gut permeability. These neurotransmitters have been implicated in several severe mental health issues so perhaps it's time we look to the gut microbiome as opposed to the brain as the source of the problem.


Stress increases the permeability of the entire GI tract, this may be known as “leaky gut.” This allows for food particles to become detected by the immune system in a dysfunctional manner creating susceptibility to food allergies and food intolerances.


Leaky gut – or increased intestinal permeability is associated with prolonged stress. We normally have a protective mucus layer that helps to keep the food particles and gut bacteria (good and bad) in our gut. But when we are experiencing prolonged stress our body’s ability to produce the protective mucus layer decreases. This then exposures our immune system to food particles and microbes to which it should not be exposed. When our immune system is exposed it can begin to over react with food allergies, food intolerance and the development of autoimmune conditions.


Stress affects the blood flow to the mucosal membrane by constricting the blood vessels thereby decreasing the nutrients and blood flow and thus suppressing mucus production. Mucus, in the case of heartburn, is protective to the esophagus, stomach and small intestines.


Stress increases visceral sensitivity appearing to create significant GI pain and discomfort.


Stress depletes antioxidants as more pro-inflammatory pathways are activated. In the Yarnell 2011 book, the author found that the organism most often associated with peptic ulcer disease (PUD), Helicobacter pylori, thrives when there is a vitamin C deficiency. Vitamin C is considered an antioxidant and essential nutrient.


Brain Gut, Brain Gut Axis

Over the last decade this area of research has dramatically increased. It has been found that this system of communication which was once thought to be brain affecting gut only is actually bidirectional. This means that our gut and microbiome also affects our brain and vis versa. When we are stressed our brain is reacting to our gut and our gut is reacting to our brain.


Interestingly enough the Vagus nerve is primarily made up of afferent fibers meaning that the gut is primarily telling the brain how to respond to various situations more so than the brain telling the gut how to behave. Hence the ‘gut feeling’ you may have in certain situations.


What does this have to do with heartburn?

When we are better able to cope with our environment, we are able to decrease our stress. This is especially true for those folks that have tried all the medications and treatment protocols to no avail. By listening to the heartburn as a message from our body, we allow our body to tell what is going on and most likely it is not because you are deficient in PPIs or Tums tabs.


For your consideration

Begin to notice your triggers for the heartburn. Memorizing is not enough. Write them down, include the time of day, food items and beverages, stressful conversations/events/news etc. Consider including your sleep, movement and joy in life as well.


Savor your mealtimes. Slow down while you eat. Take time in between bites. Consider having a meal with a friend or your family. Have a meal with good conversation. Taste your food, smell your food and chew your food. Your chewed food should basically be liquid – I like to say your stomach doesn’t have teeth! If you eat at work, pause and take a short break to enjoy your meal away from your desk.



Lastly if you are struggling with chronic heartburn and you are looking for long term relief book a free 15 minute consultation call. This is valued at $65



References

Camilleri, M. (2019). Leaky gut: mechanisms, measurement and clinical implications in humans. Gut, 68(8), 1516-1526. doi: 10.1136/gutjnl-2019-318427


Hall, J., 2016. Guyton And Hall Textbook of Medical Physiology. 13th ed. Philadelphia: Elsevier, pp.795-847.


Konturek, P., Brzozowski, T. and Konturek, S., 2011. STRESS AND THE GUT: PATHOPHYSIOLOGY, CLINICAL CONSEQUENCES,DIAGNOSTIC APPROACH AND TREATMENT OPTIONS. Journal of Physiology and Pharmacology, 62(6), pp.591-599.


Sobański, J. A., Klasa, K., Mielimąka, M., Rutkowski, K., Dembińska, E., Müldner-Nieckowski, Ł, . . . Popiołek, L. 2015. The crossroads of gastroenterology and psychiatry – what benefits can psychiatry provide for the treatment of patients suffering from gastrointestinal symptoms. Gastroenterology Review, 4, 222-228.


Yarnell, E. (2011). Gastroesophageal Reflux Disease (GERD) and Reflux Esophagitis. In Natural Approach to Gastroenterology (Vol. 2, pp. 1335–1375). East Wenatchee, WA: Healing Mountain Press. Print.





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