Gastric Surgery & Heartburn Considerations

Heartburn, also known as acid reflux, is a troublesome side effect after gastric surgery. This includes, gastric sleeve, gastric bypass, adjustable band and duodenal switch. They all have a risk factor of heartburn.

But let’s face it, heartburn is an issue for more than 60 million Americans every month. Additionally, when it becomes chronic its classified as GERD, Gastroesophageal reflux disease. Therefore, a demand for some type of intervention developed. Particularly, something that could provide relief.

And rightfully so. If you’ve ever experienced heartburn, it can be debilitating. Matter of fact, it interferes with your quality of life, as it can cause sleepless nights, painful symptoms and can be downright annoying!

If you are interested in discussing your heartburn issues click here to setup a free consultation!

Everything changed in 1989

Let’s take a stroll back to the late 1980’s, when the first proton pump inhibitor(PPI) was introduced. It significantly changed how heartburn and acid reflux were treated.

PPIs provided relief to so many sufferers. They are potent agents that reduce acid secretion in the stomach

They quickly became a top selling prescription medication.

In fact, a study published in the Therapeutic Advances in Gastroenterology in 2018, “Proton-pump inhibitors among adults: a nationwide drug utilization study”

They observed between 2003 – 2015 that over 1 million prescriptions were filled during this study period. Not to mention the $10 Billion in sales in the US.

The most common PPIs currently used are…

-Prevacid(Iansoprazole)
Prilosec(omperazole)
Protonix(pantoprazole)
AcipHex(rabeprazole)
Nexium(esomeprazole)
Dexilant(dexlansoprazole)

They’ve been so popular and recognized as safe, the first prescription PPI was granted approval for over-the-counter sales in 2003.

Now, you no longer need a prescription to get heartburn relief.

Over-the-counter PPIs are…

Prevacid 24 hr
Nexium 24hr
Prilosec OTC
Zegerid(PPI w/antacid)

Disconnected treatment

Although I believe PPIs have their place. It just seems one important question has been missed.

Why?

Why are you experiencing heartburn?

You see, identifying what is causing the heartburn is an important piece. Although conventional medicine provides so many positives, the unfortunate thing is the root cause is never explored.

Rarely, do doctors have time to explore the reason you’re experiencing the symptom. The “business” of healthcare has prevented the option for providers to have adequate time to search and evaluate what is truly causing this discomfort. When you explain you have heartburn, 9 out of 10 times you will likely be prescribed a PPI.

As the saying goes… “A pill for every ill.”

What would be helpful is after starting a PPI, there was a plan to work through finding the root cause behind your symptom. Fix the problem, then wean you off the PPI.

The unfortunate reality is a PPI is started and if the symptom still persists, the dose is increased.

In fact, one study found “patients were increasingly treated for longer durations than recommended by clinical guidelines and mainly with higher doses.”

What are the risks 33 years later?

New research is showing there are risks related to long-term use of PPI medications. The most documented consequences with long-term use are…

osteoporotic fractures
c-diff, pneumonia & norovirus infections
gut dysbiosis
hypomagnesemia(low levels of magnesium)
hypocalcemia(low levels of calcium)
vitamin B12 deficiency
acute gastroenteritis

There is additional concerns but have weaker studies…

Potential causes of heartburn after gastric surgery

First off, let’s dig into some potential causes of heartburn after gastric surgery.

Causes of heartburn..

Hiatal hernia
H. Pylori
Ulcers
SIBO
Pathogenic bacteria
Poor chewing
Low stomach acid
Zollinger-Ellis syndrome
Stress
Obesity
Bile reflux

As you can see, there can be several reasons one would experience heartburn. So let’s chat about a few of these.

First, fix the obvious

Simple causes are often less explored. Yet, powerfully impact the incidence of heartburn and shouldn’t be discounted.

For example, stress and poor chewing may seem meaningless, but in my experience should be step one for anyone experiencing digestive discomfort.

Second, Hiatal hernia heartburn after gastric surgery

Furthermore, hiatal hernias are when the stomach migrates above the diaphragm. No matter the amount of the stomach is above the diaphragm, you will likely experience heartburn. The interesting thing is hiatal hernias can slip back down into place. However, some will require surgery to correct.

Currently, they do find that gastric sleeve patients experience heartburn more than roux-en-y gastric bypass patients, with hiatal hernias and H. Pylori being recognized causes of this.

Third, H. Pylori driven after gastric surgery

This leads us into H. Pylori. Helicobacter pylori(H. Pylori) is a bacteria that resides in the stomach that lowers stomach acid and is considered an infection. It makes you more susceptible to ulcers and gastritis. As well as stomach cancer when left untreated.

Not to mention, it’s very common in the obese population. In fact, the prevalence of H. Pylori prior to bariatric surgery has a very large range. Studies show obese patients prior to surgery have an H. Pylori bacterial infection in 8.7%- 85.5% of all patients preoperatively.

Most typically, a Urea Breath-Test is administered to evaluate the presence of H. Pylori. But there are also DNA based stool tests that can pick up the presence of the bacteria in your poop!

This is one reason I use the GI Map stool test. It’s more sensitive at detecting the DNA of H. Pylori. In addition, it provides virulence factors AND antibiotic resistance genes. Helping you choose the appropriate treatment options to eradicate. As a side note, there are evidence based treatment interventions for H. Pylori without using antibiotics.

Fourth, low stomach acid

What about low stomach acid? To most that sounds like the perfect scenario, but in fact it’s the opposite of what you want.

As a matter of fact, adequate stomach acid is the foundation to a healthy digestive tract.

The tricky part is low stomach acid(hypochlorhydria) can look and feel just like excess stomach acid.

The most common symptoms of low stomach acid are:

heartburn
reflux
abdominal pain
bloating
gas
diarrhea
constipation
undigested food in your poop
excess burping

Why you need stomach acid

So why is stomach acid so important? You have to think of it as a…

protector
signaler

Stomach acid protects you by killing off bacteria that you are exposed to in your food and environment. Preventing pathogens from overgrowing. More specifically, small intestinal bacterial overgrowth(SIBO).

In addition, stomach acid is also responsible for breaking down dietary protein. This aids in the prevention of food allergies associated with incomplete digestion of protein.

To continue, stomach acid also acts as a signaler to other digestive properties required to properly digest and absorb the food you consume. Not to mention, it’s also essential for the absorption of minerals such as iron, magnesium, calcium, potassium & zinc.

Understanding pH

But to further explain, it’s all about the pH. If the pH is too high it won’t kill off bacteria or signal other digestive properties to be released. Further impacting absorption of key nutrients.

Technically, stomach acid should be around 1-3 acidic pH. A fun fact is battery acid has a pH of 0.8! Pretty crazy to think your stomach has the ability house something so acidic. Which is why it’s so important for it to be sealed INSIDE your stomach.

This is why you have a sphincter at the bottom of your esophagus entering the top of your stomach. It’s called the lower esophageal sphincter(LES). This is NOT altered with gastric sleeve, gastric bypass, adjustable band or duodenal switch.

However, you also have another sphincter at the bottom of the stomach entering into the small intestines. This sphincter IS affected after gastric bypass surgery. Hence the name “bypass”. This outlet is stapled off and a new small outlet is created to allow food to empty directly into the intestines without delay. Where as the gastric sleeve, adjustable band and duodenal switch maintain both sphincters.

So when someone says “low stomach acid” it indicates a high pH. This essentially means the stomach is more alkaline. To clarify, your stomach should be acidic not alkaline.

Stomach pH after gastric surgery

A study published in the European Journal of Pharmaceutics & Biopharmaceutics 2021, found the stomach pH varies following bariatric surgery.

What they found was…

Pre surgery pH 1.8(acidic)
One-day Post Gastric bypass pH 6.4(alkaline)
One-day Post Gastric sleeve pH 4.9(alkaline)

The majority of bariatric surgeons utilize some form of PPI after gastric surgery. One reason for using PPIs is to help heal the tissue right after surgery, but it just seems like the wrong tool for the job.

Adding a PPI doesn’t help lower the pH. PPIs suppress excess acid, but how can you suppress an alkaline environment? Simple, ADD acid.

Although there are some great surgeons that quickly wean you off PPIs, there are many that leave their patients on these medications for decades. Setting them up for so many digestive issues and macro and micronutrient deficiencies.

Gastric surgery and heartburn PPI alternatives

So what are your options if you don’t want to take or stay on PPIs for heartburn? Or question if it’s just covering up a deeper problem

This is where I’d like to give you hope.

Although some of you may require PPIs long-term, because you truly have excess acid. MOST of you could switch to something safer without contraindications OR come off of them completely.

But to clarify, you should NEVER stop any medication without discussing with your provider first. Additionally, PPIs shouldn’t be abruptly stopped. In doing so, you would likely experience rebound reflux when not weaned appropriately.

So what are your options?

First off, work with a provider

First and foremost, working with providers like myself to help you discover what’s driving the heartburn is step one. But while you’re digging into your root cause

Some may realize they don’t even want to go on a PPI because of their health history. So what are your options?

Second, restore pH balance

Let’s refer back to the stomach pH variations after bariatric surgery. You’ll recall the stomach pH after gastric sleeve and gastric bypass are more alkaline, not acidic. And adding acid will lower the pH making a more acidic environment. Just to refresh, your stomach is supposed to be acidic not alkaline.

This is where adding Betaine HCL(hydrochloride ) can be helpful. One important contraindication to consider is ulcers. If you have or think you may have an ulcer after any gastric surgery, Betaine HCL would NOT be recommended.

Our WLS formulated digestive enzymes utilizes betaine HCL as a core ingredient. Additionally, other important ingredients that support the digestive process are ox bile, pepsin, and enzymes that help break down protein, fat and carbohydrates.

This helps create the optimal environment for digestion and absorption. Although some may require higher dose of betaine HCL, our formula has been successfully used with thousands of gastric bypass and gastric sleeve patients. Improving digestion and heartburn.

Third, DGL

Third, we move on to an option that can be used to prevent the onset of heartburn or as a rescue treatment and healing agent.

DGL(deglycyrrhizinated licorice) is an herb that helps protect the stomach by promoting mucous secretions. It is very safe to use. Just make sure to buy it with the glycyrrhizin removed because this component increases blood pressure.

Our Gastric Health DGL is glycyrrhizin free and very safe to use.

DGL’s mode of action is different than acid suppressing medication. In fact, rather than inhibiting the release of acid. DGL stimulates the normal defense mechanisms. This prevents ulcer formation and stimulate healing of the damaged mucous membranes.

Specifically, DGL increases the…

blood supply to the damaged mucosa
number of cells producing the mucus that protect the mucous membranes
amount of mucus the cells produce
life span of the intestinal cell

In several head-to-head comparison studies, DGL was shown to be more effective than Tagamet, Zantac or antacids in both short-term and maintenance of peptic ulcers.

DGL is a great consideration, as it encourages healing of the intestinal tissue. In addition, it’s can be used to help wean off PPIs.

Fourth, digestive bitters

Fourth, we’ll discuss digestive bitters.

Digestive bitters are distilled-down, concentrated blends of different bitter herbs & plants. The bitterness of the herbs help stimulate the digestive system. In fact, when taken before meals it helps signal the release of bile and hydrochloric acid(HCL) naturally.

But what have studies found with digestive bitters? Certain herbs can be used to prevent and relieve dyspepsia.

Another study found the plants that have a substantial body of data in support of their digestion-enhancing activities mainly belong to one of three groups: bitter, aromatic and pungent plants.

Digestive bitters & digestive enzyme comparison

So to compare digestive enzymes to digestive bitters, enzymes are adding and bitters are releasing. Although “adding” betaine HCL will technically also increase the release.

The cool thing is, you could use both if needed. If you have SIBO, H. Pylori, hypochlorhydria(low stomach acid) or even achlorhydria(no stomach acid) it may require a multi-angle approach for a short period of time.

Another consideration is if you have an ulcer or think you might have an ulcer digestive bitters would be appropriate where betaine HCL containing digestive enzymes wouldn’t be.

Fifth, D-limonene

Fifth, we’ll discuss D-limonene.

D-limonene is a terpene extracted from citrus essential oil. It has a number of animal and in vitro trial highlighting it as a gastroprotective and GERD ameliorating agent.

Additionally, two separate clinical studies performed under a U.S. patent found that suffering from chronic heartburn and GERD significantly benefited from d-limonene supplementation.

Sixth, Aloe Vera

A study published in 2015, an open-label randomized controlled trial found that Aloe vera syrup when compared to ranitidine tablets and omeprazole capsules, was equally effective in reducing GERD symptoms in subjects.

A second randomized, open-label trial conducted in 2016 found that aloe vera syrups an adjunct to pantoprazole therapy was significantly more effective in reducing GERD symptoms compared to pantoprazole alone.

Seventh, Papaya

Papaya has been found in animal and in vitro studies that papaya has the ability to scavenge ROS and inhibit gastric secretion through histamine reduction. And it acts directly upon gastric smooth muscle to impact its motility.

Eighth, Melatonin

While the use of melatonin as a sleep aid has been well established, research as indicates its potential role in GERD and functional dyspepsia.

One trial studied patients with and without GERD. They received four interventions:

Control
Melatonin
Omeprazole
Combination Melatonin & Omeprazole

They found that the two groups receiving melatonin supplements alone or in addition to omeprazole, yields a significant increase in lower-esophageal(LES) pressure. This is great! Think of it as it’s sealing it tighter so no acid gets into the esophagus.

A single blind randomized study found 100% of the participants who took a supplement that contained: melatonin, L-tryptophan, vitamin B6, folic acid, vitamin B12, methionine and betaine reported a complete regression of their GERD symptoms. Whereas, only 65.7% of the group that took 20mg of Omeprazole reported regression of GERD symptoms.

Lastly, Low FODMAP Diet

You see bacteria love to eat carbohydrates. After they eat, they release gas. Sometimes too much. Gas causes bloating, stomach pain and pressure.

Reducing your intake of fermentable carbohydrates, like in the FODMAP diet helps the body produce less gas. This reduces pressure in the stomach. With less pressure there is less relaxation of the LES. This means your stomach contents will less likely rise into the esophagus.

So following a low FODMAP diet for a short period of time may provide relief.

In conclusion

Finally, to pull this all together. Heartburn is a symptom of something deeper going on. First off, consider the simple things first like stress and proper chewing. Then evaluate other causes such as H. Pylori, SIBO, low stomach acid, pathogenic bacteria or bile reflux. Working with someone like myself who can help you identify the root cause, as well as have a bigger toolbox of solutions can be a game changer. So if you’re struggling with heartburn or reflux, I hope you see that using the right tool for the job may be the only change you need to make.