gerd-notes

This document contains practical notes for managing gastroesophageal reflux and concomitant stomach irritation, as learned from years of personal experience. This document is divided into three top-level sections: donts, dos, and maybes. For the table of contents, click the menu icon at the upper right of this file.

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DONTs

Medicines

1. Do not use proton pump inhibitor (PPI) medicines for more than a few weeks or months. Do not use it at all for reflux. Examples of PPIs are omeprazole, lansoprazole, pantoprazole, rabeprazole, etc. The reason is that they gradually cause damage to numerous organs with extended use. Eventually this can expect to show in abnormal blood results as deteriorated kidney function via elevated BUN and creatinine, etc. The abnormalities may show faster with stronger PPIs. PPIs are okay to use only in the short term, such as for treating an esophageal ulcer that is not respondsive to other treatment, or perhaps as a part of an H. pylori treatment protocol, etc. Safe alternatives to PPIs are H2RAs; these are documented.
2. Do not use most over-the-counter antacid tablets of calcium carbonate. The reason is that these tablets always contain sugar-like additives that cause dental disease which also risks heart inflammation due to the slow leakage of bacteria from the mouth into the blood. Prominent included additives are dextrose, starch, and maltodextrin. Even the simple peppermint flavor formulation contains such additives. Flavored variants of the tablets can also contain artificial colors which are linked to inflammatory conditions. Furthermore, all such tablets are also expected to contain one or more artificial sweeteners such as sucralose, etc. that risk gut dysbiosis, with the possibility of reflux worsening due to this dysbiosis. The safe alternative to these antacid tablets is pure calcium carbonate powder, also magnesium carbonate powder to a lesser extent.
3. Do not excessively consume NSAID painkillers such as ibuprofen or others, especially if on an empty stomach or on an insufficiently-full stomach. They are associated with a substantial increase in acid secretion, also with ulcers if used chronically. Occasional use after food on a sufficiently full stomach is fine in this regard.

Supplements

1. Do not consume specific supplements that may significantly worsen reflux, although the experience can vary individually. These supplements can sometimes also exist in a product that contains a blend, in which case the blend has to be discontinued. A possible example of such a supplement is R5P (riboflavin 5'-phosphate), and it can generally be replaced by plain riboflavin. Another example is uncooked supplemental mushroom powder, although cooked mushrooms are completely fine.

Food

1. Do not eat food in disposable cardboard plates or boxes, as these may very well continue to be lined with PFAS for years to come. Such surfaces feel unusually smooth to touch for cardboard. Prefer a regular ceramic, glass, or steel plate instead as these are food-safe materials that will not expose you to toxins such as PFAS, microplastics, nanoplastics, phthalates, or bisphenols. This will not help with reflux, but it will help contribute to stomach health, with the alternative risking chronic low-grade stomach pain and systemic inflammation.
2. Do not stop eating certain healthy foods because someone says they worsen reflux. Due to the health benefits of these foods, it is best to repeatedly test and verify such assertions before taking conclusive action. These foods often are extremely nutritious, and discontinuing them comes with a cost.
3. Avoid eating a few hours before bed. Leftover food in the stomach at bedtime risks worsening esophageal reflux at night while the body is flat.

Drink

1. Do not consume alcohol regularly as it is notorious for worsening reflux and for increasing the risk of upper gastrointestinal cancers. Sufficiently infrequent consumption may however be tolerable.
2. If you drink tea, whether regular tea or herbal tea, do not use tea bags. Even paper tea bags are mixed with plastic polymers, e.g. PLA (polylactic acid), which are harmful to the human body. This is done to strengthen the bags to prevent tearing. The bags release particles into water. This contributes significantly to reflux. It is advisable to use loose-leaf tea instead, and without any plastic equipment. With regard to herbal tea, capsules of the respective herbs can be used as an alternative.

Lifestyle

1. Contrary to popular advice for reflux, consider NOT raising the head of your bed at all. Although raising the head while sleeping does help with reflux while in bed, it absolutely can misalign the spine, resulting in chronic lower back pain which subsequently also manifests as referred leg and foot pain.
2. Do not wear very tight pants, clothes, or belts, as these may risk pushing food up and thereby worsening reflux. This applies both when outdoors and indoors.

DOs

Medicines

1. Famotidine is the one and only H2RA (H2 receptor antagonist) medicine that is in standard use for reflux. It is available cheaply, widely, and over-the-counter. Ranitidine should not be used due to its historical nitrosamine contamination. Cimetidine should probably be avoided due to its numerous drug interactions that don't exist with famotidine. Famotidine is best used in multiples of 10 mg as many times needed during the day, but at least twice daily. A higher dose of 20 mg at a time may lead to an uncomfortable feeling of diminished acid production that passes with time. Unlike PPIs, famotidine is considered to be very safe for use. An issue however exists with the presence of numerous undesirable additives in all commercial famotidine tablets. These additives can be artificial colors, titanium dioxide, talc, lactose, and others. Several of these additives risk worsening reflux. Unfortunately, there is no known brand without these additives. The Berkley Jensen brand of famotidine is however an example of a lesser evil with just slightly fewer questionable additives. Berkley Jensen makes famotidine tablets in a dose of 20 mg, but the pill can easily be split into two or three or four pieces. A two-way, three-way, or four-way pill splitter can be purchased as needed for this purpose. As a reminder, taking it at least two times a day is a strict necessity.
2. It has interestingly been observed that a full course of a strong antibiotic, e.g. amoxicillin plus clavulanate, taken two or three times daily, lowers observed reflux for a few weeks thereafter. The resulting hypothesis is that this antibiotic could potentially help reflux is by killing bad bacteria that are contributing to the reflux, although eventually the bad bacteria find their way back if care is not taken. Note that this antibiotic is a powerful one, and is not safe for use without some considerations. Firstly, its very first pill can result in a significant headache, possibly caused by a mass die-off of healthy bacteria. Secondly, a powerful probiotic, e.g. Swanson 25-strain SWA030, should almost certainly be taken several hours after each pill of this antibiotic, without which there is a risk of colonization by pathogenic bacteria or fungi. Antibiotics are known to harm gut mucosal integrity, so their use is not recommended unless absolutely necessary.

Supplements

1. Gastritis is a common initial co-occurrence with reflux. Its symptoms, including the feeling of a chronically burning stomach, can be minimized by taking 500 mg of regular vitamin C once or twice daily for life.
2. For acute stomach irritation, but NOT for regular use, liposomal vitamin C can also be taken in a dose of 500 mg once or twice a week, but not much more. It is expected to help more rapidly with tissue healing. Liposomal C is a very strong IV-like form of vitamin C that bypasses the safety mechanisms of the body, risking side effects with overuse. As such, the noted limit must be strictly adhered to.
3. Zinc L-carnosine also is an excellent supplement and is greatly encouraged for healing, at a maximum daily dose of 8 mg of elemental zinc taken twice daily for life. That's a total of 16 mg of supplemental zinc per day. This dose should not be exceeded because after 2-3 months, exceeding it will lead to worsened cognition due to excessive zinc with a copper deficiency. To prevent an overdose, all other zinc supplements should be discontinued if zinc carnosine is used. As an exception, the dose can optionally be increased to 24 or 32 mg for the first month only, when starting the supplement for the first time.
4. As per PMID 12667380, folate is critical for curbing gastric inflammation. Quatrefolic is a pretty good modern supplement of folate.
5. Melatonin is linked to cancer prevention. Uncontrolled reflux is associated with esophageal and gastric cancer, so melatonin could somewhat lower this risk. The preferred nightly dose of melatonin seems to gradually increase with age. Consider these ballpark doses in mg by age: 20-25: 0.5; 26-30: 1; 31-35: 2; 36-40: 3; 41:45: 4; 46+: 5.
6. Other vitamin and mineral supplements such as selenium, vitamin E, vitamin B9 (folate), and vitamin D3, if in optimal doses, are also individually expected to lower the risk of upper gastrointestinal cancers by minimizing DNA damage, although they may not help directly with tissue irritation from reflux.
7. A good blend of probiotics, if taken daily, is expected to further support stomach health. It may help for the probiotic to be released directly into the stomach without any special acid-resistant coating to bypass the stomach. In this way, it could help crowd-out bad bacteria that may otherwise exist in the stomach. Two examples are Swanson 16-strain SWA034 and Swanson 25-strain SWA030. Between these two, the latter is more comprehensive, but it can take the body a month or two to adjust to it. Note that a probiotic is not expected to help directly with reflux. A bad probiotic product can risk making reflux worse if it were to accidentally contain an unlabeled pathogenic variant.

Powders

1. Instead of commercial antacid tablets which have harmful sugars and additives, pure calcium carbonate powder is a useful antacid for routine daily use, but it must be swallowed very slowly for it to coat the esophagus on its way into the stomach. In this way, although it is not as effective as a commercial antacid tablet, it does still work. A commercial antacid tablet is not used as it contains numerous harmful additives, including sugars, that cause dental infections and other issues. The NOW brand has a good product of calcium carbonate powder that is a 12-ounce container of it without any additive. A small metal scoop of size 1/16 or 1/8 tsp can be used, but the scoop must be kept clean and dry. It is useful to clean the scoop with soap every three weeks, and to dry it fully before reinserting it into the container. This approach also works while traveling, but the powder must be carried in its original branded container that doesn't arouse excessive suspicion at airports and borders. It is also very beneficial to take this powder before bed, for it to function overnight when the risk of damage to the esophagus is maximum due to the flat position. Excessive intake of calcium carbonate powder can slightly irritate the stomach, but this irritation is prevented or remedied by consuming a full glass of water. Magnesium carbonate powder can also be used, but it could be a weaker antacid, and unlike calcium, the body does not tolerate too much supplemental magnesium. As for the hydroxide variants, they, including magnesium hydroxide, are caustic and therefore undesirable. Note that capsules of calcium carbonate won't work at all as they neither coat the esophagus nor disperse well in the stomach.
2. Psyllium husk powder is extremely relevant for reflux. It has dose-dependently been studied to lower reflux. One of its relevant mechanisms is that it binds to bile. Its Organic product can be purchased as a powder, with the Swanson brand having a good product for it. A scoop of 5 grams of the powder can be mixed with a full glass of water, stirred well with a spoon, and consumed immediately before it coagulates. Delaying the consumption for even two minutes can cause the mixture to gel in the glass, making it significantly harder to swallow, especially with increased age. It can be taken once or twice daily. It should not be taken more than 5 grams at a time, or with less than a full glass of water, as stomach pain is otherwise expected. It should be a pure and unflavored powder, with no additives or sweetener whatsoever. It should be consumed at least two hours before and after all medications and supplements, otherwise it can interfere with their absorption by binding to them in the stomach.
3. If more support is needed for healing gastritis or mild ulcers, L-glutamine powder at a dose of 5 grams taken once or twice daily is pretty good. It is however not safe to be supplemented by anyone with any collagen overproduction or deposition disease, including but not limited to anyone with pulmonary hypertension.
4. In the absence of substantial regular meat consumption, collagen hydrolysate powder promotes tissue healing in complementary ways. It also promotes recuperative sleep. A reasonable daily dose is 8 to 16 grams, with 12 grams being close to a balanced amount. Swanson has a good product for it. The best time to take it is just before dinner, but not after dinner as it can add to a feeling of fullness. It should not be taken too close to bedtime as it may otherwise cause significant reflux while it is still in the stomach. It is not safe to be taken by anyone with any collagen overproduction or deposition disease, including but not limited to anyone with pulmonary hypertension.
5. Black raspberry powder is studied to be an inhibitor of gastrointestinal cancers. Its daily consumption is therefore encouraged, at least at 1 tsp per day. More broadly, total flavonoid intake can also independently be increased.

Food

1. Always eat slowly and consciously, chewing very well. Never eat in a rush or hurriedly. The slower you eat, and the better and longer you chew, the easier it is for the body to digest the food, and the less is the reflux.
2. Eat to minimize abdominal fat. This is because even a little abdominal fat risks gravely worsened reflux. Every extra inch of waist length can significantly worsen reflux. Both a high-processed-carb diet and a high-saturated-fat diet will typically add abdominal fat, as will the absence of sufficient physical activity. In contrast, a moderate-unprocessed-carb and high-fiber diet, if combined with some physical activity, is not expected to add abdominal fat.
3. If possible, eat at fixed times during the day. This allows the body to avoid unnecessary scheduled pre-secretion of acid. It is understandable if this is not feasible.
4. If certain foods worsen reflux, it can help to identify and minimize their intake after conducting tests, and never without such personal verification.

Drink

1. Fully clean all water related glasses, cups, bottles, and pitchers routinely. If cleaning by hand, use a deep scrubbing brush that reaches all areas, inside and outside. Fully clean them at least once every week with water, and at least once every two weeks with dish soap. Be sure that the dish soap is washed off completely, with no residue. Failure to clean them in this way will lead to the growth of bacteria, slime, and even mold, all of which risk substantially worsened reflux upon ingestion. A sudden increase in reflux symptoms can sometimes be ascribed to this avoidable cause.
2. Adding a pinch of about 1/64 or 1/32 tsp of calcium carbonate powder mixed well into a pitcher of drinking water can help make foods feel less acidic when this water is consumed. The powder won't dissolve fully, and it will mostly settle to the bottom, but some amount is expected to stay mixed with the water.

Lifestyle

1. It is okay to use a second pillow or a thicker pillow to raise the neck just slightly while in bed. This might minimize reflux just slightly while in bed. The effective pillow height should not be raised excessively, or neck pain will surely result. Slight back pain can also result, but it can be managed by alternating the pillow. Over time the pillows can flatten, so replacing them or adding to them can become necessary.
2. To the extent feasible, sleep on the left side (as opposed to the right side). This admittedly is not very practical to do for a long period, as it is habitual to routinely switch sides while sleeping.

Exercise

1. Any exercise that increases resting metabolism is good for burning abdominal fat, thereby lowering reflux. All aerobic and anaerobic exercises are expected have this effect. For those with a sedentary lifestyle, the bare minimum that must be done is to walk daily for an hour, if only at home, as this too can eventually be effective for burning abdominal fat. Time spent walking while listening to a podcast passes by quickly. Ensure excellent hydration during exercise.

Monitoring

1. A routine checkup by an experienced and trustworthy MD gastroenterologist is recommended, particularly via an upper endoscopy examination procedure which requires sedation. Be sure to check reviews before scheduling an appointment.

Reading

1. For further reading, continue with these two articles: general, nutritional

MAYBEs

Supplements

1. Alginate capsules after meals and before bed, also in combination with chitosan
2. Acetic acid / vinegar capsules after meals
3. Digestive enzymes capsules after meals
4. Deglycyrrhizinated licorice (DGL)

Drink

1. It is unclear if chlorination or fluoridation or their toxic byproducts in tap water contribute to reflux. To test, filtered water can be consumed with a filter that effectively removes these and other chemicals. Reverse osmosis (RO) removes these chemicals, but a pH plus mineralization cartridge must necessarily be used with RO, and also be replaced very regularly.

Exercise

1. Esophageal sphincter exercise as documented in DOI: 10.7759/cureus.24122

Surgery

1. Although the LINX implant surgery is promising, it doesn't always work, sometimes requiring surgical removal. Also, it is unclear if it makes vomiting difficult which can be a major safety risk in the event of food poisoning.