zondag 30 oktober 2011

Heartburn, GE Reflux (GERD), and Acid Blocker Drugs

by Jeffrey Dach MD 
Breathing Fire from Heartburn GE RefluxJuly 2009 study of Acid Blocker Drugs shocked the medical community, reporting the drugs actually caused the symptoms they are supposed to treat.  The study recruited asymptomatic healthy volunteers who took Acid Blocker drugs for a few weeks, and then stopped.  Upon stopping the Acid Blocker drug, more than 40% of the volunteers reported heartburn and acid regurgitation, symptoms they never had until after they stopped the Acid Blocker drug. 
(These drugs are Prolisec, Nexium Aciphex, Protonix, and are also called PPI's for Proton Pump Inhibitors).  
Dr Christine Reimer the author, said her study revealed "unrecognized aspects of Acid Blocker -PPI drug withdrawal with acid rebound".

PPI Merry Go Round Acid Blocker Drug Nexium ProlisecThe Acid Blocker Drug Merry-Go-Round 

For the typical heartburn relieved with acid blocker drugs, symptoms return with a vengeance when the drug is stopped. This withdrawal effect is the hallmark of an addictive drug, in this case caused by "rebound acid hypersecretion" with increased gastric acid production. The worsening heartburn pain forces the victim to immediately go back on the PPI acid blocker drug, and continue indefinitely into the future.

Windfall Profits from An Addictive Drug
With 5% of the population taking acid blocker PPI drugs, this represents a blockbuster profit for the drug companies.   Ask any street corner drug dealer, and they will tell you the best business is the addictive drug business, the clients always return for more.

PPI's Are As Safe As Placebo

Your doctor probably tells you acid blocker drugs are safe, with no adverse effects.   An article in a mainstream medical journal (AAFP) says," The frequency of adverse effects associated with PPIs is similar to that of placebo".  This is not exactly true as you will see below.

Adverse Effects of PPI Acid Blocker Usage
The adverse effects of Acid Blocker Drugs are related to the profound reduction in gastric acid.  They really do their job well, reducing stomach acid to virtually nothing.   
Most of the adverse effects of PPI's are related to the fact that stomach acid is needed for digestion and absorption of food, in particular key nutrients like B12, calcium, Iron and Protein.  The 5% of our population on PPI drugs are at risk for hip fractureB12 deficiency, amino acid deficiency, and iron deficiency anemia.  One study showed reduced cognition from PPI's.
Secondly, Gastric Acid serves as a defensive barrier to invading bacterial organisms and kills any ingested bacteria, before it can overwhelm the body's defenses.  With stomach acid turned off by the PPI drug, these bacteria are free to invade.  This results in increased incidence of pneumonia, as well as Clostridia Difficile Entero-Colitis in patients on PPI's.

PPI Drugs Cause Gastric Polyps, Paralysis of the Stomach and Gut Dysmotility

Gastric Polyps from PPIs

Endoscopic view of stomach showing Gastric polyps and hyperplastic folds due to PPI drugs. Courtesy wikimedia commons
Dr A Breck McKay, in a letter to the British Medical Journal, said " long term use of PPIs cause gastroparesis, delayed total gut dysmotility and bloating" Patients suffer  acute, explosive, exacerbation of their gastritis and reflux, on attempted cessation of the PPIs. While the PPI drugs block acid production, these drugs actually stimulate hormones like gastrin, cholecystokinin, and glucagon which in turn stimulate growth of acid producing cells to massively increase and thus, are able to produce large quantities of acid, suddenly, when inhibition from the acid blocker PPI drug stops.

Handed Out Like Candy
Nonetheless, PPI drugs are handed out freely, like candy. Dr. Yeomans advised  physicians not to "over-react" to concerns about the biological effects of inhibiting acid secretion with proton pump inhibitors. 

What Causes GE Reflux and Acid Heartburn?

GE reflux on barium X Ray

Xray showing reflux of barium contrast into esophagus (red arrows) courtesy of wikimedia commons.
The cause of reflux is well known. Firstly, there is a mechanical problem with the lower esophageal sphincter (valve) which allows gastric contents to go back up into the lower esophagus.  See Image at left of Barium Xray.  The white barium has refluxed back up into the esophagus (red arrow). The acidic gastric contents causes irritation, damage and heartburn pain.  Turning off gastric acid with a blocker drug will relieve the symptoms, but does not address the underlying mechanical problems. 
 As a radiologist for 30 years, a large part of my job was taking pictures of GE reflux with barium X-rays.  I never saw reflux when the patient was standing up.  We were able to induce GE reflux before our eyes merely by placing the patient down in the supine position with the motorized table controls.  Now, with the patient in the supine position (lying down) turned back and forth on the table, we then see the reflux on the xray flouriscopic screen, with the barium contrast spilling up from the stomach into the eophagus.  

Stay Standing Up or Sitting Up For Three Hours After a Meal.Whenever I saw the GE reflux, I would then inform the patient they have reflux, and that it is important to stay standing up or sitting up for three hours after they eat a meal.  GE reflux cannot occurr in the standing or sitting position.  After three hours, the stomach should be empty, so it should be safe sleep for the night.

Eradicate the Helicobacter Pylori

 Helicobacter Pylori in the Gastric Mucosa (red arrow) jeffrey dach md

H. Pylori bacteria (red arrow) imbedded in stomach lining. Courtesy of wikimedia commons.
Secondly, there may be a co-existing bacterial infection in the stomach called H. Pylori detected with a simple blood test. Eradiction of the the H Pylori infection with antibiotics is an important step to ending the heartburn/reflux and getting off the PPI Merry Go Round. Thirdly, lifestyle and dietary modifications described below by Dr Hyman are essential to ending the heartburn.  Avoid spicy foods, eat smaller meals, do not lie down after meals, stay standing or sitting up for three hours after a meal.

 Mastic Gum – an Ancient Remedy – Kills H. Pylori

Mastic Gum is an old remedy used for centuries as a chewable gum effective against H Pylori. This is readily available at the health food store.  An excellent article on Gum Mastic by Karina L. Gordin appears in the October issue of the Townsend Letter.  She interviewed Dr Leo Galland who recommended Mastic Gum in capsule form (1000 mg twice a day) to a patient with gastritis.  Not only did the gastritis clear up, underlying ulcerative colitis also went into full remission. A 1998 landmark article in the New England Journal of Medicine on Mastic Gum, showing activity against H Pylori, is largely responsive for renewed interest in this old remedy.  See references below for more on Mastic Gum.

Simple Steps to Get Off Your Acid Blocking Drug This 7 minute video by Mark Hyman MD is an excellent summary: 
The H. Pylori Story, The Nobel Prize and The Eradication of Gastric Ulcers

Gastric Ulcer on Barium X-ray, a rare bird no longer seen

The Disappearing Ulcer. Barium X-Ray showing typical appearance of benign gastric ulcer (red arrow) with classical radiating folds. Triple therapy has eliminated this. Courtesy of Wikimedia Commons.

The Disappearing Gastric Ulcer
The 2005 Nobel prize was awarded to Barry J. Marshall and  J. Robin Warren for the recognition of H. Pylori infection as the causative agent in gastric and duodenal ulcrs.  With this great discovery, medical science is now able to cure gastric and duodenal ulcers by eradicating the H Pylori bacterial infection.  This is done with "Triple Therapy" consisting of two antibiotics and a PPI acid blocker drug.  Once the ulcer is cured, treatment is discontinued.

Benign gastric ulcer endoscopic view jeffrey dach mdA Rare Bird, Gone Away. Endoscopic view of benign gastric ulcer crater (center) with typical radiating folds. Courtesy of wikimedia commons.

Changes During My Radiology Career  

When I started out as at the beginning of my career as a radiologist in 1976, Gastric and Duodenal ulcers were quite common, and a large part of my job was using Xray imaging to make the diagnosis. I found many ulcers in my day.  Not any more.  Triple therapy for H. Pylori has made gastric and duodenal ulcers ancient history, these are now quite rare, an ancient relic of the past, destined for the medical museum. (link)

duodenal ulcer UGi air contrast barium exam

A Photo for the Museum showing a typical Duodenal Ulcer crater (red arrow) on air contrast upper GI X-Ray. Contrast agent is barium and effervescent CO2 crystals.  We rarely see these any more. Courtesy Wikimedia Commons.
Financial Disclosure: I do not have a financial interest in any drugs or products mentioned in this article.

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