A friend of mine with CF who lives in South Africa has a history of severe  gastroparesis (delayed gastric emptying) and low stomach acid, which (alongside her Crohn's, CFRD, and removal of her terminal ileum, ascending colon, and gallbladder years ago) has caused her significant digestive distress and inability to digest anything other than her extremely regimented liquid diet. For years Paula's gastroparesis has been so bad that if she doesn't eat precisely the right thing in precise quantities at precisely the right time of day, her stomach will not empty, which puts pressure on her diaphragm and lungs and can cause significant respiratory distress and vomiting. She is a great researcher and has tried many, many things to help this situation, but nothing had yet made a significant dent on these distressing symptoms (including multiple motility drugs). I've tried to strategize with Paula to figure out what was causing or had caused the issue, and secondly what do we do about it now. After a lot of trial and error, it seems we've found two things that have made a big difference in her life: lecithin and artichoke leaf (Cynara scolymus). 

As a kid with CF, I was lucky in that I had heartburn rarely enough that regular use of antacids or PPIs (proton pump inhibitors) was not offered to me by my parents or doctors, so I never developed a dependence on them. But it seems such things are often suggested to CF patients as part of a standard CF routine. Due to a number of factors common in the CF lifestyle (poor diet, frequent antibiotic usage, stress, coughing, etc.) acid reflux, heartburn, and gastroesophageal reflux disease (GERD) are commonplace in the CF population. Yet mainstream medicine understands the problem entirely wrong, and so their standard treatment protocol ends up exacerbating the issue and causing more problems than you started with. I want to briefly discuss why antacids and PPIs are inappropriate for CF (and humans in general) and some alternatives to these pharmaceutical treatments for reflux. 

I mentioned in my section on protein that its complete digestion is dependent upon adequate levels of hydrochloric acid in the stomach (i.e. stomach acid). I have heard (and experienced it when I was a little kid) that on top of everything else, CFers commonly have issues with acid reflux, heartburn, or GERD (gastroesophageal reflux disease). As it turns out, acid reflux is caused by too little stomach acid, not too much, and it is in turn directly related to bacterial overgrowth in the guts. I'm sure you've heard from anti-acid commercials that heartburn is caused by too much stomach acid so the simple solution is to take anti-acids... then become dependent on them for the rest of your life (don't you love it when corporations come up with these kinds of schemes?). In reality, taking anti-acids makes the problem worse by further suppressing stomach acid secretion. In this post I will discuss why stomach acid is important, what causes heartburn, and how to fix it at the roots of the problem. 

Why We Need Stomach Acid
The stomachs of meat-eating animals (that's us, by the way) are designed to be acidic in order to break down the proteins in meat into amino acids for absorption, and in order to kill any pathogens we may ingest along with our food. The healthy human stomach should have a pH of 3 or lower (the lower the pH, the more acidic). When stomach acidity rises to 5 or above, this allows bacteria to be able to thrive, causing infections in the G.I. tract, which in turn cause reflux, gas, constipation, and indigestion. Studies have shown that stomach acid secretion decreases with age [1], and that the occurrence of acid reflux and gut infections increases with age. There is essentially no one that suffers from too much stomach acid, except in extremely rare cases. When those suffering from symptoms of acid reflux or GERD are treated for low stomach acid their symptoms improve or disappear, proving that heartburn is not caused by high stomach acid but low stomach acid. 

Low stomach acid reduces the absorption of iron, B12, folate, calcium, and zinc from proteins. One study found 80% of those observed with anemia had low stomach acid [3]. Also, B12 must be separated from the protein matrix by stomach acid. If stomach acid is low, any any protein-bound nutrient, including vitamins A, E, B1, B2, B3, must be taken with supplemental hydrochloric acid (Betaine HCL) in order to be absorbed. 

If you're a CFer, you cough up and inevitably swallow a lot of bacteria-laden mucus. But if our stomach acid is too low, the bacteria-laden mucus that enters our stomach when we swallow it is not getting killed. This sets us up for infections of the gut, possibly with the bugs from your lungs. At the very least, it disrupts the ecology of the intestinal flora down there. So it seems to me that treating low stomach acid in CF, if you have it, is an absolute must for a lot of reasons. 

Furthermore, the secretion of pancreatic enzymes is triggered by food with a low pH (mixed with stomach acid) entering the small intestine. If stomach acid is too low, the secretion of pancreatic enzymes will not be triggered, and carbs/proteins/fats cannot be properly digested. However, since CFers take supplemental pancreatic enzymes, we can bypass this issue to some extent. This may be why we don't suffer from the same symptoms of carbohydrate malabsorption that those with intestinal diseases like Celiacs and Crohns disease do. Our supplemental enzymes are not dependent on pH to be released so we always have enough amylase, protease, and lipase on hand. However, that does not solve the problem of inadequate protein digestion in a stomach with too little acid, and it does not solve the problem of vulnerability to bacterial gut infection.

What Causes Reflux?
Symptoms are caused by a faulty lower esophageal sphincter (LES), which is the gateway between your stomach and your esophagus (see diagram above). The LES should only be open when passing food from the esophagus into the stomach and when belching. However, an increase in intra-abdominal pressure pushes food and acid up through the LES into the esophagus, causing burning of the esophageal tissue. Furthermore, the LES closes in response to acidic conditions, but if there is not enough acid in your stomach (if it suppressed by antacids or by bacterial infection) your sphincter may not get the signal to close, allowing acid to move up into the esophagus. Intra-abdominal pressure is caused by carb and protein malabsorption, which in turn cause bacterial overgrowth, which is itself partially caused by low stomach acid. Studies have shown that regularly taking anti-acids (like Prilosec) can cause bacterial overgrowth in the guts [2]. 

By now you are familiar with the concept of carb malabsorption and the bacterial overgrowth that can result. Similarly, if we don't digest proteins well enough, bacteria can feed on them, leading to putrefaction and the release of gas. The release of gas, either by carb malabsorption or protein malabsorption, can increase the intra-abdominal pressure and cause reflux. 

Furthermore, when carbs and proteins are improperly digested and begin to feed bacterial overgrowth, this can cause leaky gut syndrome and autoimmune disorders. In addition, asthma can be caused by reflux, and it has been shown that when stomach acid gets into the windpipe, the ability to move air in and out can drop ten fold [2].  

Having low stomach acid can also facilitate an infection of the stomach and small intestine with H. pylori. Small bowel bacterial overgrowth (SIBO) caused by H. pylori has been found to cause irritable bowel syndrome [4]. 

How to Fix Low Stomach Acid and Acid Reflux
The first and most important step towards resolving the underlying cause of acid reflux and low stomach acid is to remove long-chain carbohydrates from the diet (i.e grains, most starches, all sugars except monosaccharides). This can be done by following the Specific Carbohydrate Diet or the GAPS diet (Gut and Psychology Syndrome). Doing this will remove the possibility of carbohydrate malabsorption leading to bacterial overgrowth. 

Next, we need to supplement our inadequate stomach acid secretion with Betaine HCL pills. Taking HCL with a protein-rich meal is important for making sure we properly digest the proteins we consume and adequately assimilate the protein-bound vitamins that we need. If you are considering supplementing with HCL, I suggest you read these three posts on the SCDLifestyle website for more information on how to do it: how to test for low stomach acid, how to fix a broken stomach, and how to supplement with Betaine HCL. 

A more traditional way to address the issue of low stomach acid and a faulty lower esophageal sphincter is to take a bitter herbs tincture before and after meals. This gently encourages the stomach to produce more acid when taken before a meal, and when taken after a meal the acidity of it can cause the sphincter to close, ensuring no acid will reflux up into the esophagus. 

If there are existing issues of painful inflammation or ulcers of the stomach or esophagus due to a protracted GI infection or a degradation of its mucosal lining, taking mucilaginous herbs like comfry and marshmallow, as well as mucous membrane-healing herbs like meadowsweet may be necessary before attempting to rebuild the stomach acid with bitter herbs or Betaine HCL. In addition, if the root cause of your symptoms is an H. Pylori infection of the stomach or small intestine, taking goldenseal will help kill the bacteria, soothe and rebuild the mucosal lining, and encourage the secretion of stomach acid to get everything rebalanced. Talk to a local herbalist or naturopath on how to best take these herbs. 

Lastly, we need to rebalance our intestinal ecology by eating more probiotics. Eating beneficial bacteria that can compete with harmful bacteria is a really good idea, plus these guys help us break down the foods that we can't break down ourselves. Not only should we be taking probiotic pills (find them in the wellness section of your food coop or on vitacost.com), but we should also make sure we are eating some form of probiotic food everyday. I eat at least a tablespoon of sauerkraut everyday. It tastes great and restores my intestinal flora all at the same time! You can also drink kombucha and beet kvass, two probiotic beverages. You can make sauerkraut, kimchi, kombucha, kvass, and a ton of other lacto-fermented foods at home for dirt-cheap. If you eat dairy or grains, make sure that they are cultured, meaning fermented and alive. Most commercial yogurts you buy in the grocery store are not probiotic, and hardly fermented at all in the first place. If you eat dairy (which I do not recommend), eat whole-milk unpasteurized yogurt that you make at home from raw organic milk, or drink keifer. 

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[1] http://chriskresser.com/what-everybody-ought-to-know-but-doesnt-about-heartburn-gerd
[2] http://chriskresser.com/how-your-antacid-drug-is-making-you-sick-part-b
[3] http://chriskresser.com/how-your-antacid-drug-is-making-you-sick-part-a 
[4] http://chriskresser.com/more-evidence-to-support-the-theory-that-gerd-is-caused-by-bacterial-overgrowth