One of the symptoms many people experience frequently and most people have had sometime in their adult life is heartburn. The medical term for this is pyrosis, from the Greek word pyro meaning fire or heat. Heartburn is the classic symptom of gastroesophageal reflux (GER) or reflux. Most people have heard of these terms now because you can’t sit through an hour of television these days without seeing at least one commercial if not several advertising antacids like tums or acid blockers like Pepcid AC and Nexium. Most people are not aware that heartburn is a common symptom of gluten intolerance or sensitivity.
Celiac disease, which is a severe intolerance to gluten (the major storage protein in wheat and similar proteins in barley and rye resulting in intestinal damage) is estimated to affect 1 in 133 people in the U.S. and approximately 1/100 worldwide. Most of these people are undiagnosed. Many are being treated for reflux, irritable bowel syndrome, gas-bloat dyspepsia, lactose intolerance, or just suffering ill health unaware that a gluten free diet (GFD) might relieve their symptoms if not improve them significantly.
Dyspepsia is a medical term for stomach upset, indigestion or gas-bloat abdominal discomfort. This commonly occurs in celiac disease. Stomach contractions have been shown to be impaired in celiac disease contributing to the bloating sensation. This is confirmed by diagnostic studies revealing poor stomach emptying. Delayed stomach emptying is frequently accompanied by low pressures in the lower esophageal sphincter (LES) of the esophagus or swallowing tube. The LES is supposed to be a barrier to regurgitation of stomach contents up into the esophagus. When stomach juice that is acidic refluxes into the esophagus a burning pain is typically felt in the chest that is described by most people as heartburn.
When acid frequently regurgitates up into the esophagus a burn of the lining occurs that is termed esophagitis or reflux esophagitis and defines gastroesophageal reflux disease (GERD). Celiac disease patients have been shown to have a high prevalence of GERD and reflux esophagitis. Treatment with a gluten free diet has been shown to decrease the rate of relapse of GERD symptoms. In clinical practice, many of us have observed that a gluten free diet results in marked improvement of heartburn symptoms in not just celiac disease but in many people.
As a practicing gastroenterologist, (www.thefooddoc.com) I have had patients referred to me for reflux symptoms including several who were being considered for possible surgery for GERD. Upon discovery of celiac disease or non-celiac gluten sensitivity and institution of GFD they have had improvement or resolution of symptoms. Personally, I experienced frequent enough heartburn that I was taking a daily acid blocker. When I discovered that though I had symptoms of gluten sensitivity and was DQ2 positive I had negative blood tests but elevated fecal gliadin IgA and tissue transglutaminase IgA antibodies, I initiated a GFD. My heartburn went away and I stopped taking a daily acid blocker. Now I only have heartburn rarely, usually with obvious dietary indiscretions like too much coffee, chocolate or wine.
My friend and colleague, Dr. Rodney Ford, who practices pediatric gastroenterology in New Zealand, has communicated to me his similar experience with children. Since expanding gluten free diet to those children he suspects of gluten sensitivity, not just those in whom celiac disease is confirmed by traditional or classic strict diagnostic criteria, he has noted a marked decrease in the number of children with GER. He states it has been many years since he has had to refer a child for surgery for reflux.
There have been concerns about clinical significance of known acid suppressive therapy impairment of digestion though so far the worries about the increased risk for cancer seen in lab rats have been unfounded. Recently, an increase risk of community-acquired pneumonia attributed to loss of acid reduction of bacteria in the stomach was found in patients with chronic lung disease or with other risk factors. There also is the on going debate about the high costs of the newer, more effective acid blocking drugs as well as their potential side effects. Some also raise concerns of an increased risk of food intolerance or allergy while on acid suppression. These issues and the risks of undiagnosed celiac disease not withstanding should give one pause to the idea of chronic acid suppressive therapy without investigating the possibility of undiagnosed celiac or gluten sensitivity with a trial of GFD.