Common Gastrointestinal Problems
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is GERD or Heartburn?
Gastroesophageal reflux refers to the backward flow of acid from the stomach up into the esophagus. People will experience heartburn, also known as acid indigestion, when excessive amounts of acid reflux into the esophagus. Most people describe heartburn as a feeling of burning chest pain, localized behind the breastbone that moves up toward the neck and throat. Some even experience the bitter or sour taste of the acid in the back of the throat. The burning and pressure symptoms of heartburn can last as long as two hours and are often worsened by eating food.
Over 60 million people experience acid indigestion at least once a month and some studies have suggested that over 15 million people experience acid indigestion daily.Symptoms of acid indigestion are more common among the elderly and women during pregnancy.What Are the Treatments of GERD?
In many cases, Doctors find that acid indigestion can be controlled by modifying
lifestyles and proper use of over-the counter medicines.
Avoid foods and beverages which contribute to acid indigestion: chocolate, coffee, peppermint, greasy or spicy foods, tomato products and alcoholic beverages.
Stop smoking. Tobacco inhibits saliva which is the body.s major buffer. Some studies have concluded that tobacco stimulates stomach acid production and relaxes the muscle between the esophagus and the stomach, permitting acid reflux to occur.
Reduce weight if obese.
Avoid eating 2-3 hours before sleep.
Take an over-the-counter antacid or an H2-blocker, some of which are now available without a prescription.How Common is GERD?When Should You See a Doctor about GERD?
When symptoms of acid indigestion are not controlled with modifications in lifestyle, and over-the-counter medicines are needed more often than twice a week, you should see your doctor.
When GERD is left untreated serious, complications can occur, such as severe chest pain that can mimic a heart attack, esophageal stricture (a narrowing or obstruction of the esophagus), bleeding, or Barrett.s esophagus (a pre-malignant condition of the esophagus). Symptoms suggesting that serious damage has already occurred include:
Dysphagia A feeling that food is trapped behind the breast bone.
Bleeding Vomiting blood or tarry, black bowel movements.
Choking Sensation of acid refluxed into the windpipe causing shortness of breath, coughing, hoarseness of the voice.What Type of Tests are Needed to Evaluate GERD?
Your Doctor may wish to evaluate your symptoms with additional tests when it is unclear whether your symptoms are caused by acid reflux, or if you suffer from complications of GERD such as dysphagia, bleeding, choking, or if your symptoms fail to improve with prescription medications. Your doctor may decide to conduct one or more of the following tests. Barium Esophagram or Upper GI X-Ray
This is a test where you are given a chalky material to drink while X-rays are taken to outline the anatomy of the digestive tract. Endoscopy
This test involves insertion of a small lighted flexible tube through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedatives.
Esophageal Manometry or Esophageal pH
This test involves inserting a small flexible tube through the nose into the esophagus and stomach in order to measure pressures and function of the esophagus. With this test, the degree of acid refluxed into the esophagus can be measured as well. Surgery Surgeons perform anti-reflux surgery on patients with longstanding gastroesophageal reflux disease not controlled with medication. The surgical technique attempts to improve the natural barrier between the stomach and the esophagus that prevents acid reflux from occurring.Medications Often Prescribed for GERD
Prescription medications to treat GERD and ulcers include drugs called H2 receptor antagonists (H2-blockers) and proton pump inhibitors which help to reduce the stomach acid which tends to exacerbate symptoms, and work to promote healing, as well as promotility agents which aid in the clearance of acid from the esophagus.
Since the mid-1970.s H2-receptor antagonists have been used to treat GERD and ulcer disease. In GERD, H2-receptor antagonists improve the symptoms of heartburn and regurgitation and heal mild-to-moderate esophagitis. Symptoms are eliminated in somewhat over 50% of patients with twice a day prescription dosage of the H2-receptor antagonists. Healing of esophagitis may require higher dosing.Proton Pump Inhibitors
These agents maintain remission in about 25% of patients. H2-receptor antagonists are generally less expensive than proton pump inhibitors and provide adequate, cost-effective approaches as the first-line treatment as well as maintenance agents in GERD and ulcer disease. In mid-1995, the FDA approved availability of some H2-blockers without prescription in dosage levels appropriate for treatment of heartburn.
Proton pump inhibitors (PPIs), such as omeprazole, and more recently lansoprazole, have been found to heal erosive esophagitis (serious forms of GERD) more rapidly than H2 receptor antagonists. PPIs provide not only symptom relief, but also symptom resolution in most cases, even in those with esophageal ulcers. Studies have shown PPI therapy can provide complete endoscopic mucosal healing of esophagitis at 6 to 8 weeks in 75% to 100% of cases. Daily PPI treatment provides the best long-term maintenance of esophagitis, particularly in keeping symptoms and disease in remission for those patients with moderate-to-severe esophagitis, plus this form of treatment has been shown to retain remission for up to five years.Promotility Agents
Promotility drugs are effective in the treatment of mild to moderately symptomatic GERD. These drugs increase lower esophageal sphincter pressure, which helps prevent acid reflux, and improves the movement of food from the stomach. They decrease heartburn symptoms, especially at night, by improving the clearance of acid from the esophagus. Recent developments have greatly limited the availability of one of these agents, i.e. cisapride. Cisa.
What is an Ulcer?
About 20 million Americans will suffer from an ulcer in their lifetime. Duodenal ulcers often occur between the ages of 30 and 50, and are twice as common among men.
Stomach ulcers are more common after the age of 60 and are more common in women.
An ulcer is a focal area of the stomach or duodenum that has been destroyed by digestive juices and stomach acid. Most ulcers are no larger than a pencil eraser, but they can cause tremendous discomfort and pain.What are the Symptoms of Ulcers?
The most common symptom of an ulcer is a gnawing or burning pain in the upper abdomen. The pain often occurs between meals and sometimes awakens people from sleep. Pain may last minutes to hours and is often relived by eating and taking antacids. Less common symptoms of an ulcer include nausea, vomiting and loss of appetite and weight.What Causes Ulcers?
In the past, ulcers were incorrectly thought to be caused by stress. Doctors now know that there are two major causes of ulcers. Most often patients are infected with the bacteria Helicobacter pylori (H. pylori). Others who develop ulcers are regular users of pain medications called non-steroidal anti-inflammatory drugs (NSAIDS), which include common products like aspirin and ibuprofen. The use of antibiotics toHelicobacter pylori
fight the H. pylori infection is a major scientific advance. Studies now show that antibiotics can permanently cure 80- 90% of peptic ulcers. Blocking stomach acid remains very important in the initial healing of an ulcer.
Most ulcers arise because of the presence of Helicobacter pylori. Because H. pylori exists in the stomachs of some people who do not develop ulcers, most scientists now believe that ulcers occur in persons who have a combination of a genetic predisposition, plus the presence of the bacteria, Helicobacter pylori.Use of Non-Steroidal Anti- Inflammatory Drugs (NSAIDS)
The second major cause for ulcers is irritation of the stomach arising from regular use of non-steroidal antiinflammatory drugs. NSAID-induced gastrointestinal side effects can best be avoided by using alternative therapy whenever possible. Low-dose corticosteroids or supportive drugs such as acetaminophen are alternatives to NSAIDS to consider. Four grams per day of acetaminophen has been shown to be comparable to analgesic and anti-inflammatory doses of ibuprofen for osteoarthritis pain and is not associated with an increased risk of gastrointestinal side effects. If you are taking over-the-counter pain medications on a regular basis, you will want to talk with your physician about the potential for ulcers and other GI side effects. Your doctor may recommend a change in the medication you are using, or the addition of some other medication in conjunction with your pain medication to prevent ulceration. These could range from switching to acetaminophen, use of antacids or a prescription product (such as misoprostol) in conjunction with your pain medication.What are the Complications of Ulcers?
- Bleeding: Bleeding from an ulcer can occur in the stomach or the duodenum and is sometimes the only sign of an ulcer. Bleeding from an ulcer may be slow, causing anemia and fatigue. More rapid bleeding can cause bowel movements to become sticky and tarry black or even bloody. Bleeding ulcers may cause nausea and vomiting of acidified blood that looks like ?old coffee grounds.?
What Everyone Should Know About
- Perforation: When ulcers are left untreated digestive juices and stomach acid canliterally eat a hole in the intestinal lining. Bacteria, food and digestive juices can spill into the abdominal cavity causing sudden,intense pain that requires hospitalization, and often surgery.
How are Ulcers Diagnosed?
- Obstruction: Chronic inflammation from an ulcer can cause swelling and scarring to occur. Over time scarring may close the outlet of the stomach, preventing the passage of food and causing vomiting and weight loss.
Most doctors recommend that a test be performed to evaluate for the presence of an ulcer if symptoms are not improved after two weeks of treatment with an acid blocking medicine (cimetidine, ranitidine, famotidine, nizatidine, omeprazole or lansaprazole etc.). The tests most commonly used to evaluate for ulcer are an X-ray known as an Upper GI Series or UGI, and a procedure called an Endoscopy or EGD.
- Upper GI Series: This is an X-ray test where you are given a chalky material to drink while X-rays are taken to outline the anatomy of the digestive tract.
Tests for Helicobacter pylori
- Endoscopy: This test involves insertion of a small lighted flexible tube through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedatives. During the test, tissue biopsies can be taken for examination. A biopsy will not cause any pain or discomfort, and is usually only the size of a match head.
There are several tests available to your doctor to evaluate for the presence of the bacteria, H. pylori. Samples of blood can be examined for evidence of antibodies to the bacteria; a breath test can be examined for by-products from the bacteria; or biopsies from the stomach can be examined.How are Ulcers Treated?
In the past, doctors advised patients to avoid spicy, fatty and acidic foods. We now know that diet has little to do with ulcer healing. Doctors now recommend that patients withulcers only avoid foods that worsen their symptoms. Ulcer patients who smoke cigarettes should stop. Smoking has been shown to inhibit ulcer healing and is linked to ulcer recurrence. In general, ulcer patients should not take NSAIDS like aspirin or ibuprofen.When is Surgery Necessary?
Most ulcers can be healed with medications. When an ulcer fails to heal or if complications such as bleeding, perforation or obstruction develop, surgery is often necessary.MEDICATIONS OFTEN PRESCRIBED FOR ULCERS
Prescription medications to treat GERD and ulcers include drugs called H2 receptor antagonists (H2-blockers) and proton pump inhibitors which help to reduce the stomach acid which tends to exacerbate symptoms, and work to promote healing, as well as promotility agents which aid in the clearance of acid from the esophagus.H2-Receptor Antagonists