An Ayurvedic Perspective on GERD (Gastroesophageal Reflux Disease)
GERD occurs when digestive juices moves upward from the stomach into the esophagus causing acid reflux, which over time can damage the lower esophageal lining and an increase the risk of precancerous Barrett’s esophagus. The causes of GERD can vary from diet and lifestyle factors to obesity, pregnancy, hiatal hernia and the relaxing of the lower esophageal sphincter. Factors such as smoking tobacco, eating too late at night and certain common trigger foods such as coffee, tea, alcohol, chocolate, spicy foods and tomatoes can also play a role in the worsening of symptoms.
Common Symptoms of GERD
- Acid reflux
- Heart burn
- Esophageal spasms
- Chest pain (retrosternal)
- Regurgitation of food
- Difficulty swallowing
- Chronic cough
An Ayurvedic Perspective on Digestion
To understand GERD and other related digestive disorders, lets first explore the Ayurvedic concept of Agni, the power of digestion. Agni is present within saliva, stomach acids, bile, and enzymes of the pancreatic and small intestine. When Agni is strong it supports robust appetite, optimal digestion, energy, satisfaction and overall vitality. Below is a list of various classifications of digestion according the classical Ayurvedic text on pathology and etiology- Madhava Nidana.
4 Clinical Varieties of the Digestive Fire
- Manda Agni occurs when the slow and sluggish nature of kapha dosha impair the digestive fire. This results in symptoms such as low appetite, slow digestion, heaviness in the stomach, food stagnation, acid reflux, sluggish bowels (not dry) and phlegmatic disorders.
- Tikshna Agni occurs when the sharp and hot qualities of pitta dosha impair the digestive fire. This causes symptoms including intense appetite, hypoglycemia, hyperacidity, gastric or bile reflux and inflammatory digestive disorders.
- Vishama Agni occurs when the erratic nature of vata dosha deranges the digestive fire. Here, the appetite and digestion are variable and food may be digested well at some times and poorly at others with symptoms such as gas, bloating, abdominal discomfort, dry constipation and lower bowel disorders.
- Sama Agni is the balanced state of Agni, where appetite and digestion is optimal, the body is light and energetic and satisfaction is experienced after eating a meal. A strong Agni within the g.i tract mirrors itself at the cellular level, as the specialized metabolic fires (dhatu agni) situated within each of the 7 dhatus (bodily tissue elements), thereby aiding in their nourishment and serving as a sentry to guard the gates of the deep tissues of the body against invading influences excess dosha and ama (uneliminated metabolic waste products).
The first three varieties of Agni mentioned above fall into the category of Agni Mandya, or impaired digestion, and serve to gauge the slow, variable or intense nature of the digestive fire. It is important to note these states of Agni can become mixed. For example, individuals may have an intense appetite, yet variable to slow digestion, yet at other times may have optimal digestion, yet become prone to certain types of digestive disturbances form time to time. As a general rule, the closer to balance we are, the easier it is to heal and recover our heal.
General Causes of Agni Mandya (dyspepsia)
- Eating or drinking too much, too little or the wrong types of foods for our constitutional needs.
- Eating on the go.
- Erratic meal times.
- Not chewing food well.
- Eating too late at night or too close to bedtime.
- Drinking too much liquid at or close to mealtimes.
- Drinking too much iced water or chilled drinks.
- Doshic Imbalances (constitutional influences).
- Stress factors (mental, emotional or physical).
Constitutional Influences on Digestive Disorders
Generally disturbances that are related to a single dosha imbalance are easily corrected with dosha management pertaining to diet and lifestyle and herbal remedies. Dual-dosha imbalances are more challenging and may require specific herbal treatment and dietary observances over a longer period of time. Tridoshic imbalances, involving vata, pitta and kapha, are more serious and can become extremely difficult to treat. Although, due to modern technological advancements in medicine and surgery, we can now address more severe conditions to preserve life and health. Yet it remains essential to remove any causative factors and when possible the root cause itself. This type of approach will greatly assists other forms of treatment and to establish cure or management of a disease. If we only correct structural issues and remove a diseased tissues or organ, but do not address the underlying imbalance, dosha and/or ama can again accumulate and manifest in another predisposed area of the body.
In relation to digestive health, if Agni is disturbed for prolonged periods of time and the contributing factors to a condition are not corrected, more serious digestive disorders can manifest including peptic ulcers, diverticulosis, increased gut permeability (leaky gut syndrome), candidiasis, SIBO, as well as autoimmune diseases such as Crohn’s disease and ulcerative colitis. Here, the understanding of the qualitative expression a particular disorder is an important key to preserving and maintaining digestive health. In Ayurveda, specific foods and herbs are selected to counter the qualitative imbalances and assist in bringing about balance and healing. If there is too much cold or damp/wet quality diminishing Agni, then warming digestive stimulants like ginger, black pepper or pippali can help to kindle Agni. If there is too much dry quality disturbing digestion and elimination, moistening herbs such as shatavari, licorice root, marshmallow root or slippery elm are helpful. If there are symptoms of burning and inflammation, herbs that are cooling, moistening and protecting, like shatavari, vidari kandha, gulwel sattwa and licorice are beneficial along with other cooling herbs/substances such as kama dudha, shanka bhasma, prawal panchamrit or prawal pishti.
Another traditional classification of indigestion is known as Ajirna. Here, the normal state of Agni is disturbed. When the digestion is disturbed it can have a negative effect upon the mind and emotions. Here, vata can create anxiety, fear, worry, insecurity, and mental confusion; pitta can cause volatile emotions such as anger, hatred, sustained irritability and being hypercritical; whereas kapha dosha can intensify feelings or greed, possessiveness and attachment. Conversely, if the mind and emotions become disturbed, they can in turn disturb the doshas. Below a few of the various types of Ajirna relating to the three dosha are described according to the classical text Nidana Panchakam.
- Ama Ajirna: Here the increase of ama (toxins) weigh down the power of Agni and can cause sinus congestion, heaviness of the body and the burping up of food. This type of Ajirna is often connected with kapha dosha and manda agni. Traditionally, formulas including trikatu churna, ama pachak vati and agni-tundi are used.
- Bistabdha Ajirna: This type if indigestion is associated with increased vata dosha and causes abdominal discomfort due to trapped or excessive gas. A lack of mental focus and generalized stiffness, aches and pains can accompany this condition. Here, formulas such as hingwastak churna and chikrakadi or lusunadi vati are beneficial.
- Vidagdha Ajirna: Here, pitta dosha is disturbing Agni creating regurgitation that is intensely sour tasting and generalized feeling of heat. Low energy can be experienced that is related to ranjaka pitta disturbance governing liver and gallbladder function. Here, the herbs guduchi, gulwel Sattwa or amalaki are used as well as avipattikara churna to support agni and clear heat and ama without provoking pitta. If the appetite is low due sama pitta (pitta with ama), shanka vati is a good choice and can be taken after meals.
GERD and the Doshas
A common misunderstanding in Ayurveda is that hyperacidity and heartburn are typically associated with the aggravation of pitta dosha, although a weakened digestive fire often plays a more significant role in acid indigestion and GERD related symptoms in general. HCL (hydrochloric acid) is a primary expression of Agni and pachaka pitta within the stomach, which gradually diminishes with age, but can be hastened by a poor diet and lifestyle. Low HCL causes ingested food to sit too long within the stomach, as in the case of manda agni or ama ajirna, causing the regurgitation of its contents. If this type of condition is treated as a pitta disturbance with the use of primarily soft, heavy and moistening demulcent herbs such as shatavari, licorice or slippery elm or bitter and cooling substances such as guduchi, kama dudha, praval pishti (red coral powder) the condition may not improve. Here, warming and pungent digestives and carminatives may be needed to kindle Agni and burn ama. Mixed dosha conditions require skill with formulation to address needs of the patient. For example, heating and drying herbs may be combined with soft, moist and cooling herbs to create the proper balance of qualities and properties in a formula.
Furthermore, disturbed vata dosha creates an accumulation of air in the stomach (amashaya kupita vata), leading to frequent burping and belching and even arrhythmia or pseudo-cardiac pain in some individuals. Overtime, this type of imbalance can cause even increased risk of hiatal hernia or weakening of the lower esophageal sphincter, both major contributors to GERD. Other conditions such as vishama agni or vistabdha ajirna can cause abdominal distention causing undue upward pressure, thus contributing to GERD and its related symptoms.
We can see clearly how the power of digestion can be effected in many ways and on many levels. Symptoms of acid indigestion must be investigated fully and limited to pitta imbalances. In fact, a good majority GERD cases are associated with a decrease of Agni, possible due the widespread lack of physical activity, poor nutrition and dietary habits and stress factors of our increasingly fast paced world. I have also noticed that pitta predominate individuals who have historically been blessed with a strong appetites and good digestion, may eventually develop conditions relating to weakened Agni when the amount of food taken isn’t adjusted based on activity levels and the overall tendency for a slower metabolism as we age.
Common triggers of GERD
This is a basic list of GERD triggers, yet each individual can present with different sensitivities due to the nature of the situation and constitution.
- Eating large portions
- Eating a full meal within 2-3 hours before bedtime
- Laying down on a flat bed
- Processed oils and deep fried foods
- Refined sugar and grains
- Drinking alcohol, coffee or tea
- Certain medication such as ibuprofen and aspirin
- Hot spicy foods
- Sour foods such as citrus and tomatoes
- Smoking tobacco
Ayurvedic Herbal Approaches
Food remaining too long within the stomach is one of the primary causes of GERD and the regular use of over the counter antacid may only work to complicate the condition. Herbal treatment can be a valuable addition to treating this condition, but it is important to not simply rely on herbs or antacids geared towards quelling the digestive fire. There are times where is it important to pacify the flames of digestion and other times to increase it. A thorough investigation will prove invaluable when selecting the right combination of herbs as well as the right dietary suggestions to bring about a qualitative shift in the condition and reestablishing of digestive health.
Demulcent Herbs: Herbal demulcents are softening, moistening and protecting to the mucosal membranes of the g.i. tract associated with kledaka kapha. They are mainly pacifying to vata and pitta and increasing to kapha. They are highly mucilaginous and cooling in action and include herbs such as licorice, slippery elm, marshmallow root, psyllium husk and shatavari, whereas cinnamon (all varieties) is heating, yet shares similar moistening and demulcent properties. Demulcents are helpful when pitta is the primary dosha responsible for acid indigestion and heartburn and when there is tikshna agni. If the digestive fire is low, as in the case of manda agni, demulcents can be used to some degree to protect the membranes of the esophagus, stomach and small intestine, yet will not address the root cause of low Agni. Here, herbs that kindle appetite and digestion will be needed too.
Carminative Herbs: Carminatives are herbs the help to improve overall digestion and range from heating to cooling in action. Spice herbs like cumin, coriander and fennel and are neutral to cooling and help to support Agni without aggravating pitta. Others such as ginger, black pepper, rosemary, mustard seeds or asafoetida (hing) are heating and pacifying to kapha. This category of herbs is useful to improve and maintain healthy digestion, reduce flatulence and related abdominal discomfort.
Digestive Stimulant Herbs: Most digestive stimulants are heating like ginger, black pepper and pippali, yet some such as cumin and fennel help to stimulate digestion without generating excess heat in the body. Heating digestive herbs may also play an important role in the treatment of GERD that is causes by slow and sluggish digestion as is the case in manda agni or ama ajirna, but should be used with caution when pitta is disturbed in order to not further irritate the gut. A good example of a digestive stimulant is dried ginger root, which kindles Agni and burns ama (toxins) and decreases to kapha. Moderate amounts of heating herbs can pacify vata, but can dry the tissues in excess. Fresh ginger is less heating and can be tolerated by most people when taken in moderation. If pitta is too high creating hyperacidity, stimulants should be avoided, but in the case where pitta is associated with ama (sama pitta) or ama ajirna, digestive bitter herbs can be taken periodically improve appetite and quickly stimulate digestion without increasing heat and pitta dosha.
Antacid Mineral Substances: There are many herbs and mineral substances that possess pitta pacifying properties that reduce acidity including praval pishti (red coral powder), kama dudha, shanka bhasma (conch shell ash) and sajikshar (sodium bicarbonate). Small amounts of these substances can be added to herbal based formulas too quickly reduce and neutralize acid secretions when such actions is needed.
Pitta Specific Digestive Herbs: Common herbs used in Ayurveda to pacify pitta related digestive disturbances include amalaki, avipattikara churna, coriander, guduchi, musta, shatavari, red rose petals and demulcent herbs such as licorice root.
Kapha Specific Digestive Herbs: Common herbs used to pacify kapha related digestive disturbances include ajwan, chitrak, garlic, dill seed, ginger root, black pepper, pippali, and trikatu churna.
Vata Specific Digestive Herbs: Common herbs used to pacify kapha related digestive disturbances include asafoetida (hing), ajwan, dashamula, fennel, ginger, hingwastak churna and mineral salt.