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"Weakened" LES

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Posted 10/4/2011 1:38 AM (GMT 0)
I've been pondering over the various causes for the LES to malfunction and am listing them here:

1. Hiatal Hernia
2. Low pressure at the LES junction
3. Transient relaxations of the LES
4. Angle of His getting more obtuse than normal (during pregnancy and being overweight and such).

I guess any of the above could constitute as what they refer as "weak" LES? What are the causes for #2 (low pressure)?

In order to get the LES to go back to functioning to where it used to be - in the case of:
#1 Hernia (surgery is the only fix)
#4 If pregnancy is involved, it will get corrected after the pregnancy ends - if overweight issue is involved, it will get corrected if one loses weight.

But in the other cases, can the LES ever go back to normal? Do they have statistics out there about whether it does or not?

I personally know some people who got 100% better after a few months of struggle - are not on any meds and only occasionally experience the heartburn symptoms now. Does it mean their LES is back to functioning in an "almost" normal way? Changing diet etc. is not going to make the LES stronger / better - it only provides for a lighter "load" for the "weakend" LES to handle.

some thoughts i was pondering .. so thought I'll post them here to get some feedback ...
Posted 10/4/2011 1:42 AM (GMT 0)
good topic, and interesting. I can tell you I have a hiatal hernia and at one point went symptom free for 6 months (and I ate tonnes of non-reflux friendly foods during that time). I only got GERD again due to a stupid strong antibiotic (Levaquin). So even in cases of hiatal hernia I think you can get better w/o surgery, at least that was my case for that time.
Posted 10/4/2011 3:39 AM (GMT 0)
i suspect the cause of number 2, low pressure at the les - stomach junction may be due to the displacement between the LES and the crural diaphragm

studies halve shown that half the closing pressure of the LES is due only in part to the exertion of the les itself...and about half is the reinforcement the LES receives from the part of the diaphragm that surrounds it...the crura

the displacement may be a result the the herniation of the hiatus..im not sure

btw

my guess is that the cause of number 3...the transient relaxations of the LES, is neurological and-or emotional

you raise interesting issues

be st wishes
mt
Posted 10/4/2011 10:03 AM (GMT 0)
Yes interesting subject. I'm convinced some of my problems are damages from pregnancy - I vomited endlessly both times and all the health issues I have now have only appeared since childbirth (though of course other things have happened in that time frame; bereavements, getting older etc etc).

I didn't understand until recently that the LES is not a sphincter like other the other sphincter muscles at our tail ends....... it's actually a flap and in structure it is far more like a heart valve than a sphincter. No wonder stuff leaks!!

I think lots of folk have hernias and don't know about it. I know 2 people who have proven hernia and have zero symptoms. And I agree, it's due at least in part to a weakness in the diaphragm and yet no treatment is ever aimed at correcting the diaphragm. Why is it that we (with hernias) have a weak spot in our diaphragms and yet the answer is to kill off our stomach acid?! Is there no way to repair the diaphragm??

I have asthma and I wonder a lot if the asthma itself or the medication for it are contributory to GERD. Certainly long acting beta agonists (LABA's - long acting ventolin) have been proven to reduce the pressure of the LES and I no longer take that kind of asthma medication for that reason. But it hasn't made any difference to my symptoms.

MMM
Posted 10/4/2011 11:08 AM (GMT 0)
Yes, this design is seriously flawed .. and I wish we could "evolve" our bodies in a single lifetime :).

I was told though that some amount of acid is actually good in the esophagus - as it kills the bad bacteria there and such - may be that is why the LES is a flap and needs to leak out a small amount of acid up - and may be this "feature" has led to the breakdown of the other safeguards ..

anyway .. not that we can fix all this ourselves .. we'll need the medical community to work on these issues .. wish I was in medical research .. at least I would've contributed to help people with such problems ..
Posted 10/4/2011 11:44 AM (GMT 0)
Yes definitely flawed engineering - or is it just that we're not using this model in accordance with its design specifications?!

MMM
Posted 10/4/2011 12:20 PM (GMT 0)
MMM and PPI-LESS-
Actually you are combining 2 different things. There is a gastroesophageal flap valve and a Lower Esophageal Sphincter. The first thing is the gastroesophageal flap valve and then the LES. This is if you are heading into the stomach. The LES is actually right at the esophagus/stomach junction and the gastroesophageal flap valve is a little farther up the esophagus.

If you have seen pics from an EGD you see the scope going into the gastroesophageal flap valve that is above the LES.

Take care,
Bill
Posted 10/4/2011 3:59 PM (GMT 0)
http://www.hon.ch/OESO/books/Vol_4_Prim_Motility/Articles/ART063.HTML

Hi Bill

I was lead to believe (by a doctor) that the LES is not a sphincter muscle with the same kind of structure as the anus. From this article it looks like they're still debating it's exact physiology, but I don't think it's a ringed muscular structure that can shut tight.

http://www.barrettsinfo.com/content/info_2b1_les.cfm
This article on Barrett's refers to the LES as a valve.

What I was meaning was that my mental picture was of something that should be closing tight shut like other sphincters, but it doesn't have that kind of structure.

MMM
Posted 10/4/2011 4:29 PM (GMT 0)
amazing thread

im following the discussion and the links...what an education...thanks all ; mt
Posted 10/4/2011 5:11 PM (GMT 0)
my 2 cents worth,

I realize the PPI prescribed by my doctor treats only the symptoms: heartburn. It doesn't treat the cause. The cause and effect chain is:

Hiatal hernia / ? -> weakened LES -> acid reflux -> heartburn

From my experience, the following would weaken my LES and leads to heartburn (or the reverse)

1. not enough rest - A weakened LES doesn't have enough time to heal itself.
(this is a vicious positive feedback loop, a weakened LES causes reflux at night which leads to more restlessness and even weaker LES)

2. Abdominal pressure - simple physics, fluid flows from high pressure to low pressure. Obesity, pregnancy, overeating, tight clothes, gassy food can cause heartburn and weaken LES.

3. Chemical reason - certain food and medications are known to relax LES. Calcium channel blockers are known to relax LES. Research shows calcium ions in LES cells seem to play an important role in its relaxation and contraction. Some people suggest to take calcium supplement to improve LES. I am doing it and i felt better. But there may be other confounding factor that might contribute to the improvement. I am still observing.
Posted 10/4/2011 6:16 PM (GMT 0)
WJF,

Which foods and medications do you think relax the LES?

I have a small hiatus hernia, which probably doesn't account for a great deal of my symptoms. It certainly can't possibly account for the gastritis I also have. My hernia is so small surgery isn't indicated. My BMI is normal and I sleep like a log. I would add a 4th physiological reason - I think something causes a loss of the normal protective mucus layer, or something generates inflammation which in turn takes away that natural protective coating. From then on everything and anything irritates the stomach and possibly also the oesophagus. This is the reason for looking into (and experimenting with) the use of natural substances which are supposed to help restore the mucus layer - licorice, zinc carnosine and n-acetylglucosamine. My difficulty is that nearly everything I try causes further irritation, but I continue to deplete my pockets and my reserves of hope as I keep on trying...........

MMM
Posted 10/4/2011 7:23 PM (GMT 0)
MMM-
This is a quote from website barretsinfo,com that you showed "In addition to the LES, the gastroesophageal flap valve may close when the stomach is full"

I have seen that website a lot. That is not the only one that list the 2 separately. I did some surfing earlier in the morning and found several sites list them as 2 separate things. Everything I have read indicates the LES should close all the way after it relaxes during the swallowing sequence and allows food and liquids to pass into the stomach. The LES is helped to stay closed by the diaphragm.

Within the last year or so they have hashed out what parts are what between the stomach and esophagus from what I have been reading. There was a huge debate over what parts belonged to what organ.

Take care,
Bill
Posted 10/5/2011 12:36 AM (GMT 0)
MMM,

Your symptoms are same as mine except the extra gastritis. I don't feel pain when my stomach is full. That's easier for me to eat.

Hiatal hernia only affects LES slightly. LES should be able to function without the help of diaphragm (with hiatal hernia your diaphragm cannot help closing LES because LES appears to be slightly above)

Mint / garlic / chocolate food are known to cause relaxation of LES (at least to me).
A class of medicine called calcium channel blockers also can cause relaxation of LES.

Since you have gastritis I would suggest you take doctor-prescribed acid-suppressing medications such as PPI or H2 blocker until the symptom subsides. Do a H Pylori test. Start taking supplement only after you stop the medications. Take them one at a time. If you take them all at the same time, it's hard to figure out what works for you, what makes your condition worse.

In the mean time, check on the internet, which food are GERD-friendly.

At the time of writing, I am on my way to recovery. Symptom-free for five days now without taking medications. I did it with anxiety and emotional control, sleep control, diet control and a handful of natural supplements.
Posted 10/5/2011 8:55 AM (GMT 0)
WJF, sadly the symptoms do not subside on the treatment, even after 18 months. I cannot stop treatment as I become anaemic when not on


Bill,

Thank you. Isn't it funny that they have taken so long to agree on the anatomy!

MMM
Posted 10/5/2011 5:32 PM (GMT 0)
MMM-
Yep I agree, quite funny they took so long to come to a decision on this since they have been studying this problem for so long.


Take care,
Bill
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