• Burping up contents of stomach
• Upper abdominal distention and fullness with burping
• Upper abdominal pain
• Feeling of food trapped behind the breastbone
• Heartburn or burning pain in the chest that is
  • Relieved by antacids
  • Increased by lying down, bending over, or eating
  • Worse at night
• Abnormal taste in the mouth
• Nausea after eating
• Difficulty swallowing
• Hiccups
• Headache
• Rough / hoarse voice or sore throat and associated coughing
• Wheezing

GERD is the disease resulting from chronic acid reflux. Acid reflux may irritate the esophagus causing heartburn or chest pain, burn the vocal chords causing hoarseness. Rarely, acid reflux enters the lungs and may cause pneumonia and bronchospasm. Chronic acid reflux may lead to inflammation of the esophagus, stricture or narrowing of the esophagus due to scarring from the inflammation, an esophageal ulcer, and Barrets Esophagus, a pre-cancerous condition characterized by abnormal changes to cells lining the esophagus. Chronic acid reflux may also erode the protective enamel on teeth.

Acid Reflux, Indigestion & Food Stagnation

When the stomach is overwhelmed, indigestion ensues and food stagnates. This is why the most common type of acid reflux arises from heavy Kapha provoking foods such as cheeseburgers, burritos, ice cream and fried foods. Food stagnates because digestive organs are programmed to hold back food until properly digested. Normally, when one stage of digestion is complete, peristalsis (regular wavelike muscular contractions of the intestines) propels the food further down the digestive tract. When indigestion delays food movement, bacteria feed on the partially undigested food and multiply.

Food becomes rotten, foul smelling and gaseous as it lays stagnant in the intestine. Stagnation in the stomach, a condition known as gastroparesis, causes a subjective feeling of heaviness, burping, upper GI (short for gastro-intestinal) distension and regurgitation of food mixed with acid. Rotten food also contains chemicals released by bacteria that may increase inflammation and degradation of tissue (gastritis). Indigestion may involve one or more doshas.

Kapha type indigestion is characterized by low metabolism and mucus obstruction. Low metabolism, perhaps due to hypothyroid, makes the digestive tract cold and sluggish, and contractions of stomach muscles weak. Mucus buildup in the stomach from a diet high in sweets, dairy, wheat, red meat, and refined sugars directly obstructs the action of digestive acids. Common symptoms of Kapha type acid reflux include a subjective feeling of heaviness, acid reflux that appears after late-night meals, morning mucus and congestion in the respiratory tract, as well as a thick coating on the tongue and a tendency to gain weight.

Gastritis

Gastritis is inflammation of the digestive tract. Gastritis ultimately leads to impairment of digestive function, a Vata disorder. Infection, auto-immune disorders, loss of the protective mucus barrier, bile reflux and other pathological agents can cause gastritis. When inflamed, the folds in the stomach become enlarged and swollen. Common signs of gastritis include abdominal tenderness and teeth marks on the tongue border. One type of gastritis that causes acid reflux is chronic atrophic gastritis. Atrophic refers to 'atrophy, a medical term meaning loss of function. In atrophic gastritis, there is a loss of acid secreting cells of the stomach. The inability to secrete a normal quantity of acids is a condition known as hypochlorhydria or hypoacidity.

Infection with H. pylori, a gram negative bacteria, is a common cause of acute gastritis which may become chronic and atrophic. The organism is predominantly found beneath the gastric mucosal layer that lines the surface epithelium of the stomach. H. pylori produces abundant quantities of urease, an enzyme that functions to produce ammonia in order to neutralize gastric acid. Urease also inflames the gut wall. An interesting side note: although gastritis secondary to H. pylori infection may cause acid reflux, the neutralization of stomach acids by urease actually reduces symptoms of GERD including esophageal irritation.

The stomach is normally well protected by a thick layer of mucus. Dehydration may leave stomach glands unable to produce enough mucus. Alcohol, smoking, and spices, carbonic acid (in carbonated beverages) and hyperacidity can also erode the protective mucus barrier of the stomach, and then irritate the tissues beneath causing gastritis.

Digestion and the Blood

Most of the energy and fluids used for digestion are supplied through the blood. Thus, digestion is only as strong as the blood and circulation. A high-Vata lifestyle including overexertion and skipping meals deplete the blood. Stress effectively shuts down circulation to digestive organs. Cold temperature also constricts blood vessels and circulation. Anemia and other blood deficiencies can also cause cold temperature related circulation problems. Deficiency-related cold is associated with feeling cold often even during the summer, voiding a larger quantity of soft but formed stools, and clear, thin nasal discharge.

Dehydration reduces the production of digestive juices by the stomach, liver and pancreatic glands creating a condition of "Dry Stomach Syndrome". Consider that 2 liters of acid production a day could easily drain the blood of much needed fluids, especially in thin Vata individuals. Here are some signs of a dry stomach:

• If the tongue is dry, chances are the stomach is too.
• Dry skin is an indicator that all glands are dry, including stomach, liver, and pancreas.
• A small appetite could indicate insufficient acid production in the stomach.
• Bloating, gas and burping signify food remains partially undigested

Hypoacidity

The blood, circulatory and gastritis based deficiencies discussed above reduce acid production, a condition called hypoacidity. Hypoacidity generally causes Vata-type indigestion, characterized by frequent hunger but a feeling of fullness or heaviness after a small meal, which may be followed by upper abdominal distention, bloating and burping. Hypoacidity related indigestion is a common, if not the leading, cause of acid reflux and should be ruled out before taking antacids.

Hyperacidity

Although most western medical doctors assume hyperacidity in all cases of acid reflux, we believe hyperacidity may be the exception, not the rule, in cases of acid reflux. Hyperacidity is fundamentally associated with aggravated Pitta. It results when the blood (bhrajaka pitta) and the stomach (pachaka pitta) are overactive, making a person 'hot blooded' both emotionally and physically. Typically, symptoms appear 1-2 hrs after eating. Vasodilation, thinning of the blood and increased cardiac output together increase the rate of digestion and can cause hyperacidity. Smoking, alcohol, and excess use of sour and spicy foods are just some of the ways to over-stimulate digestive juices.

Stress, worry, anger and frustration also increase production of stomach acids (Vata pushing Pitta). Emotional stress stimulates the vagus nerve, in turn stimulating secretion of gastrin and production of stomach acids. Gastrin also relaxes the lower esophageal sphincter (LES), leaving the esophagus vulnerable to acid reflux. Via the sympathetic nervous system, stress causes blood vessels to constrict, decreasing production and quality of mucus. In addition to directly causing acid reflux, more acid and less mucus leaves the stomach vulnerable to "stress gastritis".

Whereas heaviness and low appetite are commonly associated with hypoacidity, a person with chronic hyperacidity would likely have a large appetite and feel hungry between meals. The tongue will generally have a red tip or show other heat signs including a rapid, strong and bounding pulse. Hyperacidity will show fewer signs of indigestion-related gas and bloating.

Acid Reflux and Bile Reflux

Acid reflux must be differentiated from bile reflux. Bile reflux has similar symptoms to acid reflux. Bile is an alkaline salt produced by the liver and is normally released by the gall bladder into the small intestine. Then bile emulsifies fats for absorption into the lymphatic system. Sometimes, bile backs up through the pyloric valve into the stomach causing atrophic gastritis eventually leading to acid reflux. Bile reflux may result from bile insufficiency (Vata in ranjaka pitta), gall bladder stasis (Kapha blocking ranjaka pitta), or a defective pyloric valve, and any kind of food stagnation in the duodenum. The duodenum is the section of the small intestine just after the stomach. Food stagnation in the duodenum signals the stomach to stop releasing food, causing backup and acid reflux.

Insufficient bile impairs digestion of fatty foods causing stagnation. If related to Vata deficiency, symptoms will include yellow, light colored stools, emotional instability, and hypogylcemia. Common signs of Pitta related bile obstruction are yellowing of the eyes, nails, or skin, secondary to liver distress and inflammation. Gall bladder stasis from Kapha occurs when thick bile gets stuck in the gall bladder leading to indigestion, irritability, red puffy cheeks or hands, and tiredness after eating fatty foods such as french fries or potato chips.

Western Medicine

Antacids reduce symptoms and irritation from acute acid regurgitation but they do not address the root cause. Antacids are often prescribed before determining whether the underlying cause is hyper or hypo-acidity. Antacids actually increase food stagnation and exacerbate chronic acid reflux in hypo-acidic clients. The following western pharmaceuticals can increase the risk of acid reflux:

• Non steroidal anti-inflammatory drugs (NSAIDS) including aspirin
• Anticholinergics - used to treat seasickness
• Beta-blockers - for high blood pressure or heart disease
• Calcium channel blockers - for high blood pressure
• Bronchodilators - for asthma
• Dopamine-active drugs - for Parkinson's disease
• Progestin - for abnormal menstrual bleeding or birth control
• Sedatives - for insomnia or anxiety
• Tricyclic antidepressants

Other causes of Acid Reflux

Hiatal hernia (a condition where a portion of the stomach protrudes upward into the chest), injury to the lower esophageal sphincter (LES), inflammation, and overeating can cause stomach contents to leak into the esophagus. Full or partial intestinal obstruction by compacted or otherwise stagnant fecal matter can cause backup. Increased pressure on abdominal organs during pregnancy can cause late term acid reflux. Strenuous exercise such as weight lifting increase the risk of acid reflux. Hiccup, retching, spasms, and vomiting cause the reverse flow and regurgitation of stomach contents.

Treatment of acid reflux should repair digestion, redirect food downwards, reduce inflammation, and address the root cause, as indicated above.

General Diet - Repair Digestion

In all cases, follow good eating habits to build the strength of digestive organs (agni).

Avoid the following foods and beverages

• Alcohol, cigarettes, coffee, and chocolate
• Fatty foods including fried food and cheese.
• Carbonated beverages - accumulation of gaseous carbon dioxide causes burping and acid to bubble upwards. In addition, carbon dioxide in aqueous solution forms carbonic acid, further eroding the mucus lining of the stomach.
• Tomatoes, tomato sauce
• Leftovers and other ferments such as pickles and sauerkraut
• Preservatives irritate the esophagus and stomach.
• Peppermint or Spearmint in case of hyperacidity

Favor the following foods and beverages

• Steamed greens such as Kale
• Carrots and foods with beta-carotene
• Limes, pomegranate, cranberry
• Aloe vera juice
• Fennel seeds, fresh ginger
• Okra
• Cooked, skinned cucumber

Keep a routine eating and sleeping schedule. Regular but gentle exercise improves digestion and clears stagnation. Even a brief walk of 100 paces after eating helps get the digestive tract moving. Try changing the following lifestyle habits:

• Avoid bending over or exercising soon after eating; avoid strenuous exercise
• Avoid tight fitting belts and clothing that restrict movement of the abdomen.
• Avoid working in front of a hot oven and general overexposure to sun and heat.

Sleeping Habits

Acidity is high during digestion and during Pitta time of night (10pm to 2am). While sleeping, stomach acid regurgitates more easily because the esophagus is horizontal. The following techniques can help:

• Eat your meals at least three hours before bed for the stomach to finish digestion.
• Do not lie down after eating, even during the day.
• Sleep with your body at an angle so that the head is raised about six inches above the feet. This can be accomplished by six inch blocks under the legs of the bed. Alternatively, purchase a wedge pillow.
• The esophagus lies toward the left side of the body. Sleep on the right side to raise the esophagus and avoid acid back up.

Stress Management

There are many stress reduction techniques beyond the scope of this paper useful for acid reflux. A few highlights: Do not eat when emotional. Lions pose, shaking it out, dancing, meditation and breathing exercises can relieve pent up emotions. Twisting yoga poses can also help move emotions and can improve digestion but also push acids upwards. Use with caution. Milky Oats (Avena sativa) reduces anxiety and worry. Elderberry (Sambucus canidensis) is grounding. Ashwagandha (Withania somnifera) brings calm and focus to a scattered mind. Massage relieves stress and tension.

Directing Vata Downwards

Food should move downwards instead of stagnating or moving upwards. Materials that encourage food (and Vata) to move downwards (called an 'anuloma in Ayurveda) include warm water, carminatives such as cardamom, pungent aromatics such as fennel, and bitters such as neem or dandelion. Even though bitters stimulate Vata, they equally stimulate peristalsis.

Kapha Acid Reflux

Treat Kapha Acid Reflux by clearing stomach stagnation, destroying mucus, improving metabolism and stimulating both digestion and bowel motility. Follow a Kapha pacifying diet avoiding wheat, red meat, ice-cream, cheese, refined sugars and fast food. Minimize overeating, emotional eating, and heavy foods after 5pm. Drink small sips of warm water spaced ten minutes apart to stimulate digestive function and bowel motility. Steamed bitters are soft enough for easy digestion and encourage peristaltic movement through the GI.

Clear stomach stagnation with bitter orange peel (Citrus aurantium). Destroy mucus with cardamom (Elettaria cardamomum). Improve metabolism and clear heat with amalaki (Phyllanthus emblica). Stimulate digestion with fennel (Foeniculum vulgare) and fresh ginger (Zingiber officinale). See the formula Stomach Ice: Acid Reflux Relief.

Gastritis

Treat gastritis by babying digestion, soothing the digestive tract lining, rebuilding the mucus layer, destroying parasites and clearing inflammation. Favor light, easy to digest foods that also reduce inflammation. Cool, demulcent foods like okra are ideal because they are mucilaginous and light. Avoid foods that irritate the digestive tract such as coffee and alcohol, or ones that provoke heat in the blood such as bell peppers or cigarettes. Favor cooling drinks like pomegranate, cranberry and aloe vera and herbs that clear heat such as amalaki and barberry (Berberis vulgaris). Demulcents, such as marshmallow (Althaea officinalis) and licorice root (Glycyrrhiza glabra), soothe inflammation. An anti-microbial, Goldenseal (Hydrastis canadensis), may be used in case of infection.

Hypoacidity

Treat hypoacidity by stimulating digestive secretions, rehydrating, and reducing the rate fermentation. Sips of warm water with a pinch of salt and a wedge of lime one hour before eating until the salivary glands and palate remain moistened replenish fluid loss from chronic dehydration. Take digestive stimulants such as fresh ginger and blood movers such as turmeric (Curcuma longa) to compensate for deficient blood or poor circulation. Detoxify with laxatives such as haritaki (Terminalia chebula). Reduce fermentation and proliferation of bacteria with anti-microbials such as vidanga (Embelia ribes). Demulcent foods (okra) and herbs (marshmallow root) will restore the mucus lining of the stomach. Favor nourishing anti-inflammatories such as shatavari (Asparagus racemosus) and licorice root.

Hydrating, building, and easy to digest foods such as soups with ghee, rice and carrots replenish and restore deficient fluids. Warm food with mild spices stimulate circulation and thus digestion. Stress management, especially during mealtimes, greatly improves circulation to the digestive tract. Avoid difficult to digest foods such as beans, peanuts, wheat, and egg yolks. Dried foods such as granola bars, toast, and diuretics like corn, can absorb too much fluid from the blood, increasing dehydration. A routine eating and sleeping schedule will precondition digestive organs for acid availability at mealtimes. Keep warm; a cold body temperature causes loss of fluids (cold diuresis).

Hyperacidity

The treatment paradigm for hyperacidity is to absorb excess acid and avoid stimulating the digestive tract by stress, intense emotions, or heating, spicy, or otherwise acid provoking foods. Heavy foods like barley and wheat absorb excess acids. Cooling and demulcent foods like bananas, avocado, cucumber and aloe vera soothe the mucus lining. Pomegranate and cranberry offer astringency to reduce inflammation and irritation. End meals with a small amount of sweet taste to soothe the gastric lining. Chilies, radishes and other spicy or pungent foods can over stimulate digestive juices. Ferments like pickles, wine and cheese also increase acid secretion. Sour taste generally increase digestive secretions and is usually indicative of acid in food. While acidity in tomatoes and spinach increase acid production in the stomach the citric acid in vinegar, lime and lemon actually reduce acid production. Limes are preferred because they are less Pitta provoking.

Fennel and fresh ginger share a dual advantage. They are both cooling digestives, a rare combination. Amalaki, like lime, is a cooling sour that also improves digestive function by stimulating micro-circulation and capillary bed level. Antacids such as sodium bicarbonate will help in acute cases but may fail to address the underlying cause. Lifestyle choices should address high stress and reduce emotional intensity in general.

Bile Deficiency and Obstruction

Treat bile problems by eating less fats, encouraging bile production, and in case of obstruction, diluting thick bile. Substances that increase the flow of bile and gall bladder contractions are called cholagogues. Sour taste from lemons increases production and thins bile for easy flow. Favor light foods with fewer fats such as soups with steamed or boiled greens and vegetables. Bitters stimulate bile production and contractions of the gall bladder. Some other prominent cholagogues include bhumyamalaki (Phyllanthus niruri) and dandelion root (Taraxacum officinale). Treatment of Pitta type bile obstruction/deficiency (jaundice) is beyond the scope of this paper.

Western medical doctors commonly attribute acid reflux to hyperacidity and do not normally test for hypoacidity. If you suspect hypoacidity ask your doctor to recommend testing. The following western medical tests are useful before selecting a pharmaceutical, herb, or treatment protocol:

• Acid levels in the stomach
• Presence of gastritis
• H. pylori infection or other parasites
• Presence of bile in the stomach

The following treatments are commonly used in western medicine:

• Proton pump inhibitors (PPIs) are the most potent acid inhibitors: omeprazole (Prilosec), esomeprazole (Nexium), iansoprazole (Prevacid), rabeprazle (AcipHex), and pantoprazole (Protonix)
• H2 antagonists: famotidine (Pepsid), cimetidine (Tagamet), ranitidine (Zantac), and nizatidine (Axid)
• Promotility agents: metoclopramide (Reglan)
• Anti-reflux surgery (Nissen fundoplication and others)
• Digestive enzymes for hypoacidity
• Radiofrequency therapy for Barrets esophagus.

Summary of Types

• Low metabolism
• Mucus obstruction
• Atrophic gastritis
• Dehydration
• Stress / Intense emotions
• Deficient blood construction (anemia)
• Cold blood / Poor circulation
• Hypoacidity
• Hyperacidity
• Bile insufficiency
• Bile reflux
• Structural damage / changes
• Stomach spasms
• Hiccup / vomiting / pregnancy

General Treatment Protocols

• Redirect food downwards
• Rebuild digestive strength
• Detoxify
• Soothe inflammation
• Clear stagnation from stomach, small intestine, gall bladder or colon.
• Clear heat from digestive organs
• Destroy microorganisms and parasites
• Reduce fermentation
• Restore fluids
• Reduce stress
• Build blood strength
• Rebuild mucosal layer
• Destroy excess mucus
• Disperse distension
• Reduce colic and cramping
• Lose weight
• Improve posture and alignment of digestive organs

Principal Herbs

Common Ayurvedic formulas for acid reflux include Avipattikar Churna, Sootsekhar ras, Praval panchamrit, Trikatu, and Guduchi Satva. Primary herbs for custom formulas include marshmallow, licorice root, shatavari, ashwagandha, milky oats, cane sugar, sodium bicarbonate, calcium, amalaki, neem (Azadirachta indica), barberry, dandelion, burdock(Arctium lappa), guduchi (Tinospora cordifolia), kutki (Picrorhiza kurroa), bhumyamalaki, vidanga, goldenseal, aloe vera, ginger, fennel, turmeric, cayenne, clove, cinnamon, vinegar, lemon, lime, triphala, trivrut (Ipomoea turpetrum), bitter orange peel, cardamom, peppermint.

Recipes for Acid Reflux

Pomegranate with Lime Juice & Aloe Vera

Banana with lime, ghee, and cinnamon

Kale & Carrot Soup with Ginger, Fennel & Lime

Cooked Cucumber with Fennel

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