Digestion, health and nutrition: Dr. Anil Minocha, a gastroenterologist and nutritionist

GERD Acupuncture treatment

Did you know that acupuncture may be an effective GERD or chronic reflux treatment?

Gastroesophagaeal reflux disease or GERD affects tens of millions of people in the US. Proton pump inhibitors (PPIs) are the most effective medical therapy. Patients on PPI therapy are usually started on once a day dosing. However, many patients require double dose, i.e. twice a day dosing for PPIs for relief of reflux symptoms.

Long term use of PPIs is not without long term side-effects.  Many patients choose to employ complementary and alternative medicine therapies instead. Chinese medicine is an ancient system of holistic medicine effective for treatment of variety of gastrointestinal and non-digestive disorders as well as mental conditions and has been used in this context.

Dickman and colleagues examined whether addition of acupuncture rather than another dose of PPI (omeprazole) to the regimen of once a day PPI dose for GERD would be beneficial. Acupuncture was conducted at 5 points selected to calm the stomach system. The investigators found a dramatic difference in relief by addition of acupuncture to the regimen as compared to another dose of omeprazole.

Acupuncture may work better since it treats whole body acting at multiple processes than stomach acid alone.

Do you have chronic heartburn or GERD? What treatment to you take? What are your thoughts on long term use of PPIs versus use of alternative and complimentary therapy like acupuncture. If you are taking medical treatment for GERD, would you be willing to add or even substitute it with some form of CAM? Please share your thoughts.

Yes, heartburn without acid reflux

Do you have chronic heartburn or GERD? Did you know that many patients with heartburn (chronic acid reflux) or gastroesophageal reflux disease (GERD) do not get relief even from the strongest acid blocking medications also known as proton pump inhibitors PPIs. Lack of response in "GERD" or chronic reflux patients may occur due to a variety of reasons which include:

1. Some patients may require higher than normal dose, for example twice a day PPI instead of once a day. This can be documented by doing 24 hour pH monitoring while taking the medication.
2. Although heartburn in majority of patients is due to acid reflux, it may be also occur as a result of reflux of non-acid gastric contents into the esophagus. Obviously, acid blocking medications are not going to help if the refluxate does not have much acid. These patients may be helped by anti-reflux surgery to prevent any kind of reflux.
3. A small fraction of patients may have symptoms of heartburn in the absence of any kind of reflux, acid or non-acid. Assuming cardiac etiology has been excluded, this is believed to be in part due to lowered pain threshold. Medications that raise pain threshold may be helpful to some extent. A combined pH monitoring and impedance testing can help distinguish this from acid and non-acid reflux.

Do you or someone you know have GERD or heartburn? What treatments have been effective and to what degree? Please feel free to share your thoughts. By the way, do not forget the potential benefit of lifestyle measures on chronic gastroesophageal reflux disease.

Are over the counter heartburn drugs effective?

There has been an explosion in the market for over the counter heartburn drugs like antacids, alginate/antacid combinations as well as histamine2 receptor blockers (H2B or H2RAs). The question arises, how effective are these OTC drugs?

Dr. Tran and colleagues from the Baylor College of Medicine in Houston, TX recently carried out a systematic review and meta-analysis of randomized placebo controlled trials related to these therapies. They published their findings in the journal Alimentary Pharmacology and Therapeutics (Jan 2007).

Studies conducted with H2Ras showed superiority of these drugs with respect to complete relief of heartburn, symptomatic improvement, and episodes requiring rescue antacids. There was an absolute benefit increase of 10-12 percent with this class of medications.

Based on the four studies examining the antacids, the authors found a trend towards their effectiveness with an absolute benefit of 8 percent.

Similarly, 4 studies examining the demonstrated alginate/antacid combination found this class to be superior to placebo with an absolute benefit of 26 percent.

An amazing finding was the effect of placebo. The authors found that placebo response occurred in 37 to 65% of the cases.

Recently, omeprazole a proton pump inhibitor has become available without a prescription. However, OTC omeprazole was not studied in this report.

Do you suffer from heartburn, chronically or intermittently? Do you frequently take OTC drugs? Which one is your favorite?

Risks of PPI heartburn drugs keep piling up

Proton pump inhibitors or PPIs (Prilosec, Prevacid, Nexium, Protonix, Aciphex) have been a big boon to the chronic heartburn or GERD sufferers. These PPI drugs started with a black box label warning of serious consequences of cancer to being used indiscriminately almost like a candy. Data indicate that a substantial proportion of long-term PPI users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment.

Long term use of proton pump inhibitors is providing us increasing information on their potential harmful effects. Recent data about PPIs suggests the following:

1. Increased risk of serious intestinal infections with Clostridium difficile bacteria
2. Increased risk of bone fractures
3. Bad breath
4. Bacterial overgrowth
5. Diarrhea and microscopic colitis
6. Vitamin B12 deficiency
7. Chronic muscle disease (myopathy, polymyositis)

Heartburn drugs may cause bad breath

It is believed that chronic heartburn or gastroesophageal reflux disease (GERD) causes bad breath or halitosis. Acid blocking medications have often been used for this purpose. Now comes a study suggesting that the opposite is in fact true, i.e. the potent heartburn drugs of the proton pump inhibitor (PPI) class e.g. Aciphex, Prilosec, Prevacid, Nexium, Protonix etc. may actually cause bad breath.

Dr. Camacho-Lobato and colleagues from Brazil recently presented their findings at the American College of Gastroenterology meeting in Las Vegas in October 2006 (Poster#8).

The researchers studied 23 consecutive adults with GERD. And compared them to 17 patients with dyspepsia or indigestion. Patients with oral or dental disease were excluded. Oral volatile sulphur compounds that cause bad odor in breath were measured.

These investigators found that bad breath occurred in 39 percent of the GERD as compared to only 18% in those with dyspepsia.

Because of their potent acid blocking activity, PPI have potential to cause small bowel bacterial overgrowth thus causing bad breath.

This study represents a classic chicken and egg story. Is it that GERD causes bad breath and patients were simply taking PPIs to alleviate GERD. The reverse is also possible, i.e. the halitosis occurs due to acid blocking by these drugs in GERD, and contributes to the bad breath problem caused by GERD itself also.

Do you have chronic heartburn and/or bad breath? What measures do you take for these problems?

Reflux, heartburn (GERD) and COPD

Numerous studies have linked chronic heartburn or gastroesophageal reflux disease (GERD) and bronchial asthma. Several studies have shown that GERD contributes to asthma via multiple mechanisms including aspiration and esophago-bronchial reflexes. Similar mechanisms could be in play in exacerbation of COPD or chronic obstructive pulmonary disease, which is frequently caused by smoking.

Dr. Rascon-Aguilar and colleagues from University of Florida Health Science Center in Jacksonville, Florida recently studied this issue. They wished to examine the prevalence of gastroesophageal reflux symptoms patients with COPD and the effect of reflux on the rate of COPD exacerbations and published their findings in the journal Chest (October 2006).

These investigators conducted a questionnaire-based, cross sectional survey in patients with an established diagnosis of COPD.

Of the 86 patients studied, 37% reported symptoms of reflux. They found that patients with chronic reflux symptoms suffer twice as many exacerbations of COPD as compared to those without reflux.

The authors concluded that presence of GER symptoms is associated with increased exacerbations of COPD. Chronic heartburn or reflux is therefore a modifiable risk factor for COPD.

Do you have reflux with or without asthma/COPD? What treatment do you use for reflux and does it seem to help?

Heart or heartburn?

Heart and esophagus are intimately connected. It is not just that many a times we can not differentiate between heartburn of GERD versus the heart attack. Acid in the esophagus has been known to affect coronary blood flow as well as heart rhythm.

Dr. Gerson and colleagues from the Stanford University School of Medicine recently reported on a series of three patients who had symptoms of abnormal heart rhythm as well as heartburn (GERD). Simultaneous recordings of heart rhythm as well as gastroesophageal reflux events were performed. The findings were reported in the Journal of Gastroenterology (October 2006).

Patients were treated with powerful acid suppression using proton pump inhibitors. Symptoms improved in all of the patients further reinforcing the premise that heart and esophagus are connected.

The mechanism of therapeutic action may be via the nerves connecting the heart and esophagus or cardio-esophageal reflexes. The authors concluded that patients with both abnormal heart rhythms arrhythmias) and chronic heartburn or gastroesophageal reflux disease should undergo a trial of acid suppression for relief of their cardiac symptoms.

Heartburn drugs treat heart too!

I am sure you or someone you know has raised the question, is it heartburn or heart attack? Now comes a report that heartburn and ulcer medications of the H2 histamine blocker type may actually help strengthen the heart in heart failure patients. While the data is preliminary, it is indeed exciting and of course ironic that heart and heartburn have crossed paths again.

Dr. Kim and colleagues from National Cardiovascular Center in Japan recently conducted a retrospective analysis and then a small prospective study to evaluate the effects of famotidine (Pepcid) in patients with heart failure. They published their findings in the Journal of American College of Cardiology (Oct 2006).

For their retrospective study, these investigators identified 159 patients who received famotidine among symptomatic congestive heart failure (CHF) patients and compared them to age-sex matched controls. They also conducted a prospective study in 50 symptomatic CHF patients who were treated with either famotidine or teprenone.

These investigators found that addition of Pepcid to standard treatment of heart failure reduces blood pressure, heart rate and the plasma B-type natriuretic peptide levels. In addition, the treatment improved the severity of heart failure. The patients on Pepcid had also fewer hospital admissions for heart failure.

I would like to emphasize that these results suggest a role for histamine in the pathogenesis of heart function and failure. Thus although proton pump inhibitors or PPIs (Nexium, Protonix, Prevacid, Aciphex) are more potent than histamine-2 blockers or antagonists (Tagamet, Zantac, Pepcid, Axid) for blocking acid secretion, the PPIs are unlikely to help the heart.

Do you take heartburn or ulcer medications? Do you usually get the over the counter medications or the prescription only. What are your thoughts on the TV commercials for these drugs?

Why are my reflux symptoms not getting better?

Have you wondered why your symptoms due to reflux may not be getting better despite medications for gastroesophageal reflux disease or (GERD or chronic heartburn). It just might be that you have not just acid reflux but also non-acid reflux. The GERD medications block acid from forming but do not actually prevent reflux of stomach contents into the esophagus.

Asthma is considered to be one of the common non-esophageal problems related to reflux disease. Dr. Condino and colleagues from the University of Colorado Health Sciences Center, Denver, Colorado studied children with asthma and GERD and published their findings in the Journal of Pediatrics (August 2006).

They wished to examine the proportion of acid and nonacid reflux events in children with asthma who were thought to concurrent gastroesophageal reflux. A combined impedance-pH monitoring was used to assess acid and non-acid reflux episodes. Twenty-four kids were participated in the study.

A total of 1184 reflux events were recorded. Of these, 51% were nonacid related. Similarly, 555 symptom episodes were recorded. Of these, only 27% were related to any reflux episode.

The authors concluded that kids with asthma have both acid and nonacid reflux episodes with equal frequency, but majority of nonreflux symptoms including cough is not related to reflux of any kind.

This study highlights the ongoing debate among experts about the relative significance of GERD in causing non-esophageal problems like asthma, chronic cough, laryngitis etc. This study adds to the growing data that although GERD plays a role in a subset of patients, its role in pathogenesis overall may be overrated.

Do you have GERD or any problems related to that like noncardiac chest pain, asthma, cough, laryngitis or bad breath etc? How well are your symptoms controlled? Are you satisfied with medications or have required surgery?

Are belching problem and reflux related?

Do you or someone you know has belching problem? We know that belching is a common problem as is gastroesophageal reflux. Much of the belching occurs as a result of swallowing of air. This leads to an obvious question, are belching and reflux related.

Dr. Bredenoord and colleagues from Netherlands studied this issue and published their findings in the American Journal of Gastroenterology (August 2006).

They studied 12 patients with GERD and compared them to 12 healthy controls. They found that GERD patients swallow air (287 ± 45 Vs 176 ± 24) and belch (52.4 ± 6.6 Vs 32.7) more frequently than controls.

However, based on the results of air infusion in these subjects, they concluded that that air swallowing is not the cause of increased gastroesophageal reflux.