Acid
Reflux, GERD,
Esophagitis and
Barretts Esophagus Introduction: The
gastro-esophageal sphincter is a muscle that is wrapped around the lower end of
the esophagus. It forms a valve mechanism between the esophagus and the stomach
and is normally tight enough to prevent stomach acid from flowing back into the
lower esophagus. However, in some families there is a weakness of that sphincter
so that after a meal some of the food, mixed with stomach acid, flows back into
the esophagus leading to an irritation of the lining of the lower esophagus (gastroesophageal
reflux). What is more, when these individuals sleep they have pure acid reflux,
undiluted by food. This condition is called GERD
(Gastro Esophageal
Reflux Disease).
This in turn leads to a condition called chronic esophagitis
(inflammation of the esophagus). It usually develops in the lower area of the
esophagus, where the concentration of acid is the highest. A break down
of tissue in one spot in the lower esophagus can lead to an esophageal
ulcer, which causes similar pain as stomach or duodenal
ulcers do. Over the years chronic esophagitis leads to scarring of the
underlying connective tissue of the esophagus until an esophageal
stricture(narrowing of the opening of
the esophagus) develops. This makes the esophagus even more vulnerable
to chronic irritation as on top of the acid irritation the body forces food through
with higher pressures and friction irritating the lining of the lower esophagus
even more. After decades of that abuse the esophagus develops highly abnormal
cells in its lining right there where the highest irritation has been. This premalignant
condition is called Barretts esophagus
(also Barrett's syndrome, Barrett's dysplasia or metaplasia). If this is missed,
and further chronic irritation occurs, a high percentage of cases will develop
cancer of the esophagus.
For this reason it is important to identify those who have acid reflux,
so that treatment can be given and Barretts esophagus and cancer of the esophagus
can be prevented. Symptoms of GERD: The
key symptom of acid reflux or GERD is heart burn. There may be regurgitation of
acid content into the mouth, but the acid may never reach that high and only reach
up to the lower third of the esophagus. With an acute esophagitis a burst blood
vessel can cause profuse bleeding, which may be vomited up or swallowed. The
vomited material is mostly blood and is an alarming sign causing the physician
to do an esophagoscopy, an endoscopic method to directly inspect and possibly
cauterize the bleeding vessels, on an emergency basis. Swallowed blood is being
digested and leads to melena (black stools). However, most of the time
the disease is not that dramatic. Apart from heart burn there might be a pain
with swallowing solid foods, but not so much with swallowing drinks. When stricture
develops, there might be a stinging pain right after a swallow, then there is
relief as the food passes through. With an esophageal ulcer there is a sharp stinging
pain in the lower part of the chest bone or higher right behind the center of
the chest bone. Antacids tend to relieve the pain, but this alone is often not
enough to cure it. Diagnosis: The
history often suggests the diagnosis. There are several tests that have been developed
over the years. But since the introduction of the endoscopic procedures some of
them are outdated. A barium swallow with X-ray will show the swallowing
mechanism, and document, if the sphincter is incompetent by tilting the table
in a reclining position, in which barium would leak back into the esophagus. In
the past often there were highly sophisticated motility tests and the Bernstein
acid test done, which now have been largely replaced by esophagoscopy. The advantage
of this test is that the gastroenterologist can directly see the condition of
he mucous membranes and do mini biopsies at the suspicious areas, where Barretts
esophagus or esophagus cancer may have developed. Following the test the physician
can then also start therapy for the diagnosed condition. Treatment:
Acid reflux, GERD and esophagitis is treated with a combination of the
following steps:
| Treatment of
acid reflux ,GERD and esophagitis |
- Acid producing drinks like coffee, alcohol, cola drinks etc.
have to be avoided.
- Certain foods such
as chocolates and fats as well as smoking have to be stopped as they
lower the competence of the lower esophageal sphincter.
- Avoid
certain anticholinergic drugs. Ask your doctor.
- Elevate
the head of your bed about 6 inches (doesn't work with water bed).
- Use
a liquid antacid: 1-2 tablespoons 1 hour after each meal and at bedtime in
order to neutralize the acidity of the stomach juice. Common brand names of liquid
antacids are: Diovol, Maalox and Mylanta.
- The doctor
will order an H2- blocker to suppress acid production of the stomach
lining. Commonly prescribed H2-blockers are: Ranitidine ( Zantac, Nu-Ranit, Gen-Ranitidine,
Alti-Ranitidine, Novo-Ranidine, Apo-Ranitidine). A typical dosage would be 150
mg twice per day. It would be fairly safe to use this medication on an ongoing
basis.
- The doctor may decide to also prescribe medication
with the intent to improve the lower esophageal sphincter.
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Until recently three medications were typically used: bethanechol
(brand names: Duvoid, Myotonachol and Urecholine), metoclopramide (Maxeran, Reglan,
Apo-Metoclop, Nu-Metoclopramide, PMS-Metoclopramide) and cisapride (brand name:
Propulsid, Prepulsid). However, cisapride has been taken off the market (see below
why). All of these medications have some side-effects, which limit their use somewhat.
Bethanechol's side effects are abdominal
cramps, asthmatic attacks, diarrhea, nausea and some cardiac arrhythmias.
This means, for instance, that asthmatics cannot take this medication. Metoclopramide
is more receptor specific (anti-dopamine) and therefore has less side-effects.
About 10% of people complain of drowsiness and fatigue. About 5% have dizziness,
headaches and bowel disturbances. As it elevates prolactin levels, women who had
breast cancer cannot take it. It should also not be used in patients with epilepsy
as it increases seizure activity and severity. Finally, a small number of patients
come down with Parkinson's disease like symptoms and it can produce also a condition
called "tardive dyskinesia", when used for a long time. Tardive dyskinesia
affects face muscles and muscles of the mouth and tongue. It often disfigures
the face and unfortunately is mostly irreversible. This is the reason why this
type of medication should only be used on a short-term basis.Finally,
cisapride was a gastrokinetic agent (a serotonin
receptor agonist) and until recently was quite popular. However, serious cardiac
arrhythmias developed under certain circumstances as well as permanent bone marrow
damage in a small percentage of patients (agranulocytosis). It has therefore been
banned in the US and Canada in 2001.The reason for this was that the drug is eliminated
from the system via a liver enzyme system (P450 cytochrome pathway) that many
other drugs also utilize for elimination. Certain antibiotics (erythromycin and
clarithromycin), antifungals (fluconazole, ketoconazole), protease inhibitors
(ritonavir, indinavir) and some antidepressants (nefazodone) were drugs that interacted
in this elimination system in the liver and led to toxic levels of cisapride.
I am mentioning this here as an example to show how careful the patient and doctor
have to be with new medications as it often takes several years of "post
marketing research" before all of the toxic interactions are known. Ask your
physician before you take any medication and discuss your concerns about its safety.
Also, tell the doctor about herbs or other supplements that you may be taking,
as they may interact with medications as well.
If symptoms are not quite
controlled with the above measures, it is time to use the strongest acid suppressing
medication, the proton pump inhibitors (also known as
hydrogen-potassium ATPase inhibitors). Two such powerful acid stoppers are:
omeprazole (brand names:Prilosec) and lansoprazole (brand name: Prevacid ). Usual
dosage for omeprazole is 20mg once daily, and for lansoprazole is 30 mg once daily.
The action on the acid producing cells is so powerful that within a few days the
symptoms of esophagitis or esophageal ulcer is healed. Side effects are not too
common and much more benign than described for the medications under point 7 above.
A few percentages of diarrhea, headaches and abdominal pain are listed. The proton
pump inhibitors are metabolized by the liver via the cytochrome P450 enzyme system.
This limits the applicability somewhat, but with proper care and avoidance of
interfering other medications the proton pump inhibitors are a very powerful tool
in treating ulcers and acid reflux. Pain Control: Apart from
regular drugs as explained, there is an FDA approved non-drug method available,
IceWave patches from Lifewave,
which can be used to control pain. This is mentioned in the book "Breakthrough"
by Suzanne Somers (Ref. 34) where newer insights of antiaging medicine are also
reviewed. Although the patches are placed over acupuncture points, there are no
needles involved. Nanotechnology, a newer technology, was used in the manufacturing
of these patches and infrared (heat) waves from body heat are utilized to stimulate
an acupuncture point, which modifies pain perception and reduces pain to half
or less. Medically this would be considered an excellent pain reliever. For more
info on the patches see the IceWave patches from Lifewave link above (click "products").
In the US a 5 pack of the IceWave spray is available that can be directly sprayed
onto the skin in the area where the pain is located. Your doctor will talk to
you about your particular tests and what therapy is best for your situation. There
is a wide variety of findings and severity of conditions to which the therapy
will be tailored. |
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