strange heartburn problem

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Question:

I’ve had bad heartburn-like pain in my chest for the past 5 months at varying levels of intensity.  At its worst, I’ve gone to the emergency room.  Sometimes it is almost tolerable.  This started after 10 days on doxycycline, so the initial thought was that caused irritation to the esophagus or stomach.  Accordingly, my Prevacid dose was upped and the theory was that after a few weeks of extra acid suppression, I would heal, and could go back to the 15 mg every other day dose of Prevacid I was taking originally.  Well, 5 months later, and there is really no improvement in symptoms.  In fact, I’m now on 30 mg twice a day and it’s no better: I still get excrutiating attacks ever few weeks, and the pain is always present if sometimes almost tolerable. I even switched to Aciphex for 3 weeks, but it wasn’t better than Prevacid and made me feel "strange" so I went back to Prevacid.  Now, 4 months ago an endoscopy revealed that my esophagus was fine, but there was some "slight irritation" of the stomach lining itself.  I have yet to get another endoscopy to see if it looks worse, but probably will. So, my question is why the heck am I not healing? BTW, there seems to be almost no correspondence between the level of pain and what food I eat, but I eat cautiously anyway.  Also, I never drink alcohol, I don’t smoke, and I’m under weight if anything.  I would describe the pain as not so much burning as a tightness/fullness/achiness, mostly under the sternum, but often also under the right breast area.  The later pain is a poser because I didn’t think anything but lung was over there! Thanks for any insight. John.

Response:

– Hide quoted text — Show quoted text -> I’ve had bad heartburn-like pain in my chest for the past 5 months at > varying levels of intensity.  At its worst, I’ve gone to the emergency > room.  Sometimes it is almost tolerable.  This started after 10 days > on doxycycline, so the initial thought was that caused irritation to > the esophagus or stomach.  Accordingly, my Prevacid dose was upped and > the theory was that after a few weeks of extra acid suppression, I > would heal, and could go back to the 15 mg every other day dose of > Prevacid I was taking originally.  Well, 5 months later, and there is > really no improvement in symptoms.  In fact, I’m now on 30 mg twice a > day and it’s no better: I still get excrutiating attacks ever few > weeks, and the pain is always present if sometimes almost tolerable. > I even switched to Aciphex for 3 weeks, but it wasn’t better than > Prevacid and made me feel "strange" so I went back to Prevacid.  Now, > 4 months ago an endoscopy revealed that my esophagus was fine, but > there was some "slight irritation" of the stomach lining itself.  I > have yet to get another endoscopy to see if it looks worse, but > probably will. > So, my question is why the heck am I not healing? > BTW, there seems to be almost no correspondence between the level of > pain and what food I eat, but I eat cautiously anyway.  Also, I never > drink alcohol, I don’t smoke, and I’m under weight if anything.  I > would describe the pain as not so much burning as a > tightness/fullness/achiness, mostly under the sternum, but often also > under the right breast area.  The later pain is a poser because I > didn’t think anything but lung was over there!

Not enough info here to do anything but take a wild guess. You need another EGD, plus ambulatory pH testing and esophageal manometry. HMc

Response:

Just a couple of thoughts. Have you been checked for Heliobactor Pilori infection in your stomach?  The pain you describe sounds similar to that which I had when infected. Re the pain under the right breast, I think your gall bladder is on the RHS, in behind the lower ribs.  Gall stones can cause anything from a dull ache to sharp pains in this area. Andrew. – Hide quoted text — Show quoted text -> I’ve had bad heartburn-like pain in my chest for the past 5 months at > varying levels of intensity.  At its worst, I’ve gone to the emergency > room.  Sometimes it is almost tolerable.  This started after 10 days > on doxycycline, so the initial thought was that caused irritation to > the esophagus or stomach.  Accordingly, my Prevacid dose was upped and > the theory was that after a few weeks of extra acid suppression, I > would heal, and could go back to the 15 mg every other day dose of > Prevacid I was taking originally.  Well, 5 months later, and there is > really no improvement in symptoms.  In fact, I’m now on 30 mg twice a > day and it’s no better: I still get excrutiating attacks ever few > weeks, and the pain is always present if sometimes almost tolerable. > I even switched to Aciphex for 3 weeks, but it wasn’t better than > Prevacid and made me feel "strange" so I went back to Prevacid.  Now, > 4 months ago an endoscopy revealed that my esophagus was fine, but > there was some "slight irritation" of the stomach lining itself.  I > have yet to get another endoscopy to see if it looks worse, but > probably will. > So, my question is why the heck am I not healing? > BTW, there seems to be almost no correspondence between the level of > pain and what food I eat, but I eat cautiously anyway.  Also, I never > drink alcohol, I don’t smoke, and I’m under weight if anything.  I > would describe the pain as not so much burning as a > tightness/fullness/achiness, mostly under the sternum, but often also > under the right breast area.  The later pain is a poser because I > didn’t think anything but lung was over there! > Thanks for any insight. > John.

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Response:

Protonix to an OTC

Question:

  My Doc gave me a months supply of free Protonix and my chest pains went away. I quit taking them after three weeks because I wasnt having any symptoms. (stupid I know) Well about a week later I chowed down on some great Mexican food and now my chest pains are back. The Doc gave me a prescrip for Protonix when I first went in but holy hell it’s $100 for a months supply! Im taking my last 7 days of the free protonix now but i cant afford $100 prescription. Do the OTC meds work as well? How about any Generics to these drugs?

Response:

>  My Doc gave me a months supply of free Protonix and my chest pains went >away. I quit taking them after three weeks because I wasnt having any >symptoms. (stupid I know) Well about a week later I chowed down on some >great Mexican food and now my chest pains are back. The Doc gave me a >prescrip for Protonix when I first went in but holy hell it’s $100 for a >months supply! Im taking my last 7 days of the free protonix now but i cant >afford $100 prescription. Do the OTC meds work as well? How about any >Generics to these drugs?

Mind if I ask why you take Protonix?  What your situation is and your symptoms? Im going for a gastric scope here next week… having chest discomfort, pain, etc…. Im afraid I have erosive esophagus and looking for info and advice. Im 46…..non smoker…. but heavy soda drinker….and drank a few beers as well.  What have you had to do to cure your problem?

Response:

 i was having chest pains… MD assumed it was Acid reflux…..plus I was having Panic attacks…I dont know which or if one was causing the other

– Hide quoted text — Show quoted text ->  My Doc gave me a months supply of free Protonix and my chest pains went >away. I quit taking them after three weeks because I wasnt having any >symptoms. (stupid I know) Well about a week later I chowed down on some >great Mexican food and now my chest pains are back. The Doc gave me a >prescrip for Protonix when I first went in but holy hell it’s $100 for a >months supply! Im taking my last 7 days of the free protonix now but i cant >afford $100 prescription. Do the OTC meds work as well? How about any >Generics to these drugs? > Mind if I ask why you take Protonix?  What your situation is and your > symptoms? > Im going for a gastric scope here next week… having chest > discomfort, pain, etc…. Im afraid I have erosive esophagus and > looking for info and advice. > Im 46…..non smoker…. but heavy soda drinker….and drank a few > beers as well.  What have you had to do to cure your problem?

Response:

> i was having chest pains… MD assumed it was Acid reflux…..plus I was >having Panic attacks…I dont know which or if one was causing the other

I see So you really don’t know what is going on for sure?   I mean you have not been gastric scoped to confirm that in fact you have gastric reflux??

Response:

no

– Hide quoted text — Show quoted text -> i was having chest pains… MD assumed it was Acid reflux…..plus I was >having Panic attacks…I dont know which or if one was causing the other > I see > So you really don’t know what is going on for sure? > I mean you have not been gastric scoped to confirm that in fact you > have gastric reflux??

Response:

Google my recent postings on inositol. It may well stop your panic attacks. If you are uninsured consider the OTC Prilosec twice a day which is double the recommended dose per the label but the same as a presciption Prilosec or Nexium dosewise.

– Hide quoted text — Show quoted text -> i was having chest pains… MD assumed it was Acid reflux…..plus I was > having Panic attacks…I dont know which or if one was causing the other > >  My Doc gave me a months supply of free Protonix and my chest pains went > >away. I quit taking them after three weeks because I wasnt having any > >symptoms. (stupid I know) Well about a week later I chowed down on some > >great Mexican food and now my chest pains are back. The Doc gave me a > >prescrip for Protonix when I first went in but holy hell it’s $100 for a > >months supply! Im taking my last 7 days of the free protonix now but i > cant > >afford $100 prescription. Do the OTC meds work as well? How about any > >Generics to these drugs? > Mind if I ask why you take Protonix?  What your situation is and your > symptoms? > Im going for a gastric scope here next week… having chest > discomfort, pain, etc…. Im afraid I have erosive esophagus and > looking for info and advice. > Im 46…..non smoker…. but heavy soda drinker….and drank a few > beers as well.  What have you had to do to cure your problem?

Response:

>If you are uninsured consider >the OTC Prilosec twice a day which is double the >recommended dose per the label but the >same as a presciption Prilosec or Nexium >dosewise.

Is it safe to take two Prilosec a day? Im now only taking one… and that is in the morning right after i get up. If I stick with one Prilosec only… is it best to take right before bed so as to keep acid production at min levels while laying in prone position?  Or is it still best to take one only in the AM after getting up?    Bottom line…. what is bets "timing" for taking only one pill?

Response:

> i was having chest pains… MD assumed it was Acid reflux…..plus I was >having Panic attacks…I dont know which or if one was causing the other > I see > So you really don’t know what is going on for sure? > I mean you have not been gastric scoped to confirm that in fact you > have gastric reflux??

It is important to know that an EGD may not diagnose GERD. A normal upper GI endoscopy does NOT mean that the patient is NOT having GERD. It only means that the GERD hasn’t caused enough esophageal damage (stricture, esophagitis, Barrett’s esophagus) to be visible while scoping. The only way to diagnose or rule out GERD with certainty in the face a normal EGD is by ambulatory pH testing. If the endoscopist see stricture, esophagitis, or Barret’s esophagus, then he/she can conclude that the patient has GERD. If the EGD is negative, the patient may still have severe GERD. HMc

Response:

>If you are uninsured consider >the OTC Prilosec twice a day which is double the >recommended dose per the label but the >same as a presciption Prilosec or Nexium >dosewise. > Is it safe to take two Prilosec a day?

OTC (over the counter/nonprescription) strength Prilosec  (20 milligrams) is half the dose of the common acid reflux dose  (40 milligrams) one gets from the physician. Higher dosages are used in patients with hyperacidic stomach conditions. I suspect the OTC form time release method is somewhat inferior to the prescription form. So I suggest since to it takes two to get to the higher prescription level, it would much sense to take the med at twice a day for a total of 40 milligrams. The result is $1.20 compared to several dollars per day for the Prilosec. > Im now only taking one… and that is in the morning right after i get > up.

One what? OTC 20 milligrams or 40 milligram prescription? > If I stick with one Prilosec only… is it best to take right before > bed so as to keep acid production at min levels while laying in prone > position?  Or is it still best to take one only in the AM after > getting up?    Bottom line…. what is bets "timing" for taking only > one pill?

I noted on the Medscape web site a continuing medical education article that some physicains were prescribing an additional H-2 blocker ( Pepcid, Axid) in addition to a full strength proton pump inhibitor drug such as Prilosec to prevent acid break thru. The article claimed PPI meds fail to fully prevent this acid release though they are much more effective drugs for the rest of day than H-2 blockers. At regular time a half hour before a meal or so I understand. Warning I am not a physician. These suggests are just what I’ve read somewhere or I might think I know about. It wouldn’t hurt to ask your Doc. When I retire, I leaving the United States.

Response:

>It is important to know that an EGD may not diagnose GERD. A normal upper GI >endoscopy does NOT mean that the patient is NOT having GERD. It only means >that the GERD hasn’t caused enough esophageal damage (stricture, >esophagitis, Barrett’s esophagus) to be visible while scoping.

Good point Howard. Thanks!

Response:

>I suspect the OTC form time release method >is somewhat inferior to the prescription form. >So I suggest since to it takes two to get to >the higher prescription level, it would much >sense to take the med at twice a day for >a total of 40 milligrams. The result is $1.20 >compared to several dollars per day for the >Prilosec.

Your last sentence above confuses me.  Are you saying that is would be OK to take TWO Prilosec pills a day?  But you are saying that is MORE expensive than Prilosec?  Im not understanding above paragraph at all. It sounded like conflicting advice

Response:

>> Im now only taking one… and that is in the morning right after i get > up. >One what? OTC 20 milligrams or 40 milligram prescription?

Im only taking one Prilosec pill a day for now.  And wondering if taking two is OK Or…. wondering if it bets to take the one Prilosec a day but take it at bed time rather than in morning.

Response:

>I suspect the OTC form time release method >is somewhat inferior to the prescription form. >So I suggest since to it takes two to get to >the higher prescription level, it would much >sense to take the med at twice a day for >a total of 40 milligrams. The result is $1.20 >compared to several dollars per day for the >Prilosec. > Your last sentence above confuses me.  Are you saying that is would be > OK to take TWO Prilosec pills a day?  But you are saying that is MORE > expensive than Prilosec?  Im not understanding above paragraph at all. > It sounded like conflicting advice

I don’t see why. You should be able to infer what I mean. I’ll try again. Think in terms of number of milligrams of the drug per day and not in terms of number of "pills". The use of the term pills, by the way, is somewhat derisive. Two over the counter strength TR (time released) tablets add up to 40 milligrams for a total drug cost of $1.20 per day. One prescription strength TR capsule of 40 milligrams results in a total of 40 milligrams per day at cost of several dollars per day. My estimate of the costs for you are contingent on you not having drug coverage, since with drug coverage the net prescription costs for you may well be lower than the OTC drugs costs.. If you still don’t understand, go talk to your primary care provider as I counseled earlier and see how much time he or she will give you. 20  + 20 = 40 milligrams   60 CENTS + 60 CENTS = $1.20 40 = 40 milligrams     $3.00 = $3.00

Response:

> >> Im now only taking one… and that is in the morning right after i get >> up. >One what? OTC 20 milligrams or 40 milligram prescription? > Im only taking one Prilosec pill a day for now.  And wondering if > taking two is OK > Or…. wondering if it bets to take the one Prilosec a day but take it > at bed time rather than in morning.

For what it is worth, I have been taking Protonix  for about 2 years now.  It does work and as you know very expensive.  After the first year I noticed it being less effective.  So I stopped taking it but continued buying it as long as I am insured.  I recently started using Prilosec OTC.  I have kept a log of when I take it (before dinner), what I eat and how well I slept that night.  I found that Prilosic OTC has me sleeping much better at night.  I now use it for 14 days at a time and am currently trying to learn if there are health reasons that will prevent me from using EVERY day.  They say use it for 14 days but why not more than that?

Response:

– Hide quoted text — Show quoted text -> >> Im now only taking one… and that is in the morning right after i get > >> up. > >One what? OTC 20 milligrams or 40 milligram prescription? > Im only taking one Prilosec pill a day for now.  And wondering if > taking two is OK > Or…. wondering if it bets to take the one Prilosec a day but take it > at bed time rather than in morning. > For what it is worth, > I have been taking Protonix  for about 2 years now.  It does work and > as you know very expensive.  After the first year I noticed it being > less effective.  So I stopped taking it but continued buying it as > long as I am insured.  I recently started using Prilosec OTC.  I have > kept a log of when I take it (before dinner), what I eat and how well > I slept that night.  I found that Prilosic OTC has me sleeping much > better at night.  I now use it for 14 days at a time and am currently > trying to learn if there are health reasons that will prevent me from > using EVERY day.  They say use it for 14 days but why not more than > that?

Protonix/pantoprazole and Prilosec/omeprazole or Aciphix/rabeprezole are all proton pump inhibitors. The list of adverse effects listed for each are rather similar. Prilosec/omeprazole is approved by the FDA for treatment of acid reflux disease. Many people take it a daily basis and per physicians orders take continuously. Prilosec and Nexium are quite similar. Nexium contains only the best stereoisomer found in Prilosec which contains more than one stereoisomer. What research I’ve seen indicated that it isn’t a big improvement over the older Prilosec and Aciphex is still the most effective of the PPI meds. Does this mean, I think Aciphex is best? Not exactly. I suspect that it the best drug to get healing but it may have a little higher risk of side effects. This is because the marketing departments of the drug companies don’t provide enough different dose possibilities to patients and physicians. Being that the FDA is in part a creature responsive to the drug companies and a creature given to blind bias and inertia , this will not change. Ideally compounding pharmacies would be provided with the time release granules so that physicians could titrate the drug dose so that the maintenance dose would be less likely to result in adverse effects, IMHO. Though it pretty clear most physicians couldn’t bothered at least currently with such titration of medication scheme. But with a little research from the drug companies and with some promotion I think this would be feasible. Yes, I know, this will never happen. Getting back to OTC Prilosec, understand the OTC Prilosec contains half the dose of the drug as it is commonly prescribed. Further, I suspect that timed released feature of the OTC form is inferior (if indeed it has it) to the prescription forms. So if you double dose with OTC form to reach the prescription level the drug, I’d suggest taking the tablets every 12 hours, rather than together. Understand this is against the directions on the packaging, but I say "so what". Use the money you save, to have your esophagus scoped every several years. The other nice thing about OTC form over the prescription form is that the patient can dail the dose up or down. Three times a day if they get in trouble or once a day to lessen adverse effects such as dizziness, dry mucous membranes, and abdomen pains. Now this is an idea that will upset some orthodox quacks/physicians IMHO:-) Warning I am not a physician!!

Response:

I have taken prilosec for seven years with no side effects.  20mg. once a day has been the standard dosage  prescribed by doctors. For me through trial and error anything stronger than 20mg adds no additional relief and anything less than 20mg a day has no effect. All proton pump inhibitors are timed release so you may take it any time of the day. Prilosec over the  counter $17.00 per month from Walmart. Prilosec by prescription for me previously if I did not  have insurance, $110.00 per month retail.  Nexium was developed by the drug company so they could still have a high price prescription drug It is no more effective than over the counter prilosec

Response:

>I have taken prilosec for seven years with no side effects.  20mg. once >a day has been the standard dosage  prescribed by doctors. For me >through trial and error anything stronger than 20mg adds no additional >relief and anything less than 20mg a day has no effect. All proton pump >inhibitors are timed release so you may take it any time of the day. >Prilosec over the  counter $17.00 per month from Walmart. Prilosec by >prescription for me previously if I did not  have insurance, $110.00 per >month retail.  Nexium was developed by the drug company so they could >still have a high price prescription drug It is no more effective than >over the counter prilosec

OK…. well its good to hear that one can take Prilosec long term like you have.  I really didn’t know if it was considered a long term choice or not. Im sorry you had to pay so many months back when it was still prescription only and cost so much more!

Response:

excruciating heartburn / esophagitis

Question:

Developed after 10 days on Doxycycline as treatment for prostatitis. My gastroenterologist suspects the doxycycline is the cause.  I would tend to agree, but I always took it with a full meal, so can’t quite see how it could have worked its evil on my esophagus.  Anyway, assuming I have doxy induced esophagitis, my doc put me on 30mg prevacid 1x/day, and sucralfate 4x/day.  So far, after only 1 day’s treatment, I am still in agony.  I have slept virtually not at all the past two nights because of the pain, which is still excruciating even when fully upright.  Food or lack of it does little to affect the pain.  Tylenol seems to do nothing as well. Is there any medication I can take to relieve the pain so that I can sleep and let the other medicines do their work?  I’ve heard of a "GI cocktail" that has lidocain in it that is used in ERs.  Is there something similar OTC? TIA for any and all ideas — John.

Response:

In article <95556f1e.0402110805.5b5cc475 > Developed after 10 days on Doxycycline as treatment for prostatitis. > My gastroenterologist suspects the doxycycline is the cause.  I would > tend to agree, but I always took it with a full meal, so can’t quite > see how it could have worked its evil on my esophagus.  Anyway, > assuming I have doxy induced esophagitis, my doc put me on 30mg > prevacid 1x/day, and sucralfate 4x/day.  So far, after only 1 day’s > treatment, I am still in agony.  I have slept virtually not at all the > past two nights because of the pain, which is still excruciating even > when fully upright.  Food or lack of it does little to affect the > pain.  Tylenol seems to do nothing as well. Is there any medication I > can take to relieve the pain so that I can sleep and let the other > medicines do their work?  I’ve heard of a "GI cocktail" that has > lidocain in it that is used in ERs.  Is there something similar OTC? > TIA for any and all ideas — John.

First of all, one can take prevacid 30 mg twice a day.  It is a large dose, but not that infrequently done (I’m doing it for the last month and it’s helped a lot with acid burning my throat till I could barely talk).  If you’re in the US, and using our wonderful insurance plans…..your doctor will have to get special permission for the large dose, but it can be done and it will make a big difference. Also, OTC Gaviscon is different from other antacids in that it creates a barrier of foam so the acid has a harder time refluxing.  If you take too much, the magnesium in it might give you some diahrrea – but again, for a little while, no harm done. In the health food camp:  1 tsp of aloe vera juice (pure) a few times a day.  DGL (deglycerized licorice) tablets chewed 15 minutes before meals. Put some kind of blocks under the head of your bed so that it is at an angle – they usually recommend 6 to 8 inches.   DO NOT USE EXTRA PILLOWS – you need the blocks under the top of the boxspring to create the proper angle. There are other things, such as medicines available in other countries, but not here, but those will take weeks for you to get and you’ll probably be better by then. Hope this helps and that you’re feeling better soon. Louise

Response:

flare up because of SPLENDA?

Question:

I have had heartburn incidences periodically for over 15 years. Starting at the end of September, I had the flare up from hell. Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of town.  I kept thinking to myself what was different.  I realized that I had not brought my Splenda (sugar substitute with me) and was using Equal and regular sugar.  Since I have been home, I have used only real sugar and still no pain. Coincidence?  Maybe.  But it was in September that I started using Splenda.  Anyone else ever have problems with this?  I know it is not the cause of my original problem, but it seems that it heightened the pain intensity and amount.

Response:

In article <350bd14.0312161924.63812e87 > I have had heartburn incidences periodically for over 15 years. > Starting at the end of September, I had the flare up from hell. > Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of > town.  I kept thinking to myself what was different.  I realized that > I had not brought my Splenda (sugar substitute with me) and was using > Equal and regular sugar.  Since I have been home, I have used only > real sugar and still no pain. Coincidence?  Maybe.  But it was in > September that I started using Splenda.  Anyone else ever have > problems with this?  I know it is not the cause of my original > problem, but it seems that it heightened the pain intensity and > amount.

YES!   I have been increasingly sick for over a year and recently discovered that all the non-absorbable sugars tend to cause excessive gas.  I was using Splenda almost exclusively during this time but never put the two together. In my case the increased gas definitely has been connected to increased reflux.  I have stopped all artificial sweeteners and I’m not all better, but I’m noticeably improved. I’ve been trying xylitol (Miracle Sweet) which comes from Finland and is, I believe a natural and absorbable sugar.   I think it’s ok but I’m so flared that it’s hard to tell. My gastro (AFTER I found out about the artificial sweeteners), also told me that some people have trouble with the sugars in milk products as well. Keep us posted as to how you’re doing and what you’ve found.   Louise

Response:

- Hide quoted text — Show quoted text – > In article <350bd14.0312161924.63812e87 > I have had heartburn incidences periodically for over 15 years. > Starting at the end of September, I had the flare up from hell. > Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of > town.  I kept thinking to myself what was different.  I realized that > I had not brought my Splenda (sugar substitute with me) and was using > Equal and regular sugar.  Since I have been home, I have used only > real sugar and still no pain. Coincidence?  Maybe.  But it was in > September that I started using Splenda.  Anyone else ever have > problems with this?  I know it is not the cause of my original > problem, but it seems that it heightened the pain intensity and > amount. > YES!   > I have been increasingly sick for over a year and recently > discovered that all the non-absorbable sugars tend to cause > excessive gas.  I was using Splenda almost exclusively > during this time but never put the two together. > In my case the increased gas definitely has been connected > to increased reflux.  I have stopped all artificial > sweeteners and I’m not all better, but I’m noticeably > improved. > I’ve been trying xylitol (Miracle Sweet) which comes from > Finland and is, I believe a natural and absorbable sugar.   > I think it’s ok but I’m so flared that it’s hard to tell. > My gastro (AFTER I found out about the artificial > sweeteners), also told me that some people have trouble > with the sugars in milk products as well. > Keep us posted as to how you’re doing and what you’ve > found.   > Louise

hi louise! thanks for your input.  10 days splenda free and there is a major difference.  like i said, it wasn’t what caused years of reflux, but what has amazed me is how i have controlled my diet so well and still had horrible problems while i was using splenda.  if i had eaten this way before, i would never have had a problem.  this body hasn’t seen a margarita or mexican food for 4 months now…no sodas, fried foods, fatty foods etc.  i eat small amounts intentionally avoiding that sensation of being "full".  i just eat to ease the hunger and wait and do it again when i need to.  no big dinners and i raise the head of my bed and i don’t wear tight clothing around the middle.  if splenda was indeed the "bad guy", that would explain why none of that was working very well.  i am gonna stay off the rest of 2003 and see what happens.  I WANNA GET OFF MY MEDS!!!!  anyone else out there ever had an issue with this?  howard, how about any of your patients?  i have to believe there are foods that have a negative affect on this condition in certain sensitive individuals. melanie

Response:

In article – Hide quoted text — Show quoted text -> In article <350bd14.0312161924.63812e87 > > I have had heartburn incidences periodically for over 15 years. > > Starting at the end of September, I had the flare up from hell. > > Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of > > town.  I kept thinking to myself what was different.  I realized that > > I had not brought my Splenda (sugar substitute with me) and was using > > Equal and regular sugar.  Since I have been home, I have used only > > real sugar and still no pain. Coincidence?  Maybe.  But it was in > > September that I started using Splenda.  Anyone else ever have > > problems with this?  I know it is not the cause of my original > > problem, but it seems that it heightened the pain intensity and > > amount. > YES!   > I have been increasingly sick for over a year and recently > discovered that all the non-absorbable sugars tend to cause > excessive gas.  I was using Splenda almost exclusively > during this time but never put the two together. > In my case the increased gas definitely has been connected > to increased reflux.  I have stopped all artificial > sweeteners and I’m not all better, but I’m noticeably > improved. > I’ve been trying xylitol (Miracle Sweet) which comes from > Finland and is, I believe a natural and absorbable sugar.   > I think it’s ok but I’m so flared that it’s hard to tell. > My gastro (AFTER I found out about the artificial > sweeteners), also told me that some people have trouble > with the sugars in milk products as well. > Keep us posted as to how you’re doing and what you’ve > found.   > Louise > hi louise! > thanks for your input.  10 days splenda free and there is a major > difference.  like i said, it wasn’t what caused years of reflux, but > what has amazed me is how i have controlled my diet so well and still > had horrible problems while i was using splenda.  if i had eaten this > way before, i would never have had a problem.  this body hasn’t seen a > margarita or mexican food for 4 months now…no sodas, fried foods, > fatty foods etc.  i eat small amounts intentionally avoiding that

 hi, I assume that you do know about the "standard" no-no foods such as carbonated beverages, chocolate, alcohol, mint, and for me, definitely garlic and onions.  I also discovered that the menthol in cough drops is a peppermint based substance and should be avoided. Do you find that gas builds up when you have the worst reflux? Louise —

Response:

flare up because of SPLENDA?

Question:

I have had heartburn incidences periodically for over 15 years. Starting at the end of September, I had the flare up from hell. Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of town.  I kept thinking to myself what was different.  I realized that I had not brought my Splenda (sugar substitute with me) and was using Equal and regular sugar.  Since I have been home, I have used only real sugar and still no pain. Coincidence?  Maybe.  But it was in September that I started using Splenda.  Anyone else ever have problems with this?  I know it is not the cause of my original problem, but it seems that it heightened the pain intensity and amount.

Response:

In article <350bd14.0312161924.63812e87 > I have had heartburn incidences periodically for over 15 years. > Starting at the end of September, I had the flare up from hell. > Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of > town.  I kept thinking to myself what was different.  I realized that > I had not brought my Splenda (sugar substitute with me) and was using > Equal and regular sugar.  Since I have been home, I have used only > real sugar and still no pain. Coincidence?  Maybe.  But it was in > September that I started using Splenda.  Anyone else ever have > problems with this?  I know it is not the cause of my original > problem, but it seems that it heightened the pain intensity and > amount.

YES!   I have been increasingly sick for over a year and recently discovered that all the non-absorbable sugars tend to cause excessive gas.  I was using Splenda almost exclusively during this time but never put the two together. In my case the increased gas definitely has been connected to increased reflux.  I have stopped all artificial sweeteners and I’m not all better, but I’m noticeably improved. I’ve been trying xylitol (Miracle Sweet) which comes from Finland and is, I believe a natural and absorbable sugar.   I think it’s ok but I’m so flared that it’s hard to tell. My gastro (AFTER I found out about the artificial sweeteners), also told me that some people have trouble with the sugars in milk products as well. Keep us posted as to how you’re doing and what you’ve found.   Louise

Response:

- Hide quoted text — Show quoted text – > In article <350bd14.0312161924.63812e87 > I have had heartburn incidences periodically for over 15 years. > Starting at the end of September, I had the flare up from hell. > Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of > town.  I kept thinking to myself what was different.  I realized that > I had not brought my Splenda (sugar substitute with me) and was using > Equal and regular sugar.  Since I have been home, I have used only > real sugar and still no pain. Coincidence?  Maybe.  But it was in > September that I started using Splenda.  Anyone else ever have > problems with this?  I know it is not the cause of my original > problem, but it seems that it heightened the pain intensity and > amount. > YES!   > I have been increasingly sick for over a year and recently > discovered that all the non-absorbable sugars tend to cause > excessive gas.  I was using Splenda almost exclusively > during this time but never put the two together. > In my case the increased gas definitely has been connected > to increased reflux.  I have stopped all artificial > sweeteners and I’m not all better, but I’m noticeably > improved. > I’ve been trying xylitol (Miracle Sweet) which comes from > Finland and is, I believe a natural and absorbable sugar.   > I think it’s ok but I’m so flared that it’s hard to tell. > My gastro (AFTER I found out about the artificial > sweeteners), also told me that some people have trouble > with the sugars in milk products as well. > Keep us posted as to how you’re doing and what you’ve > found.   > Louise

hi louise! thanks for your input.  10 days splenda free and there is a major difference.  like i said, it wasn’t what caused years of reflux, but what has amazed me is how i have controlled my diet so well and still had horrible problems while i was using splenda.  if i had eaten this way before, i would never have had a problem.  this body hasn’t seen a margarita or mexican food for 4 months now…no sodas, fried foods, fatty foods etc.  i eat small amounts intentionally avoiding that sensation of being "full".  i just eat to ease the hunger and wait and do it again when i need to.  no big dinners and i raise the head of my bed and i don’t wear tight clothing around the middle.  if splenda was indeed the "bad guy", that would explain why none of that was working very well.  i am gonna stay off the rest of 2003 and see what happens.  I WANNA GET OFF MY MEDS!!!!  anyone else out there ever had an issue with this?  howard, how about any of your patients?  i have to believe there are foods that have a negative affect on this condition in certain sensitive individuals. melanie

Response:

In article – Hide quoted text — Show quoted text -> In article <350bd14.0312161924.63812e87 > > I have had heartburn incidences periodically for over 15 years. > > Starting at the end of September, I had the flare up from hell. > > Nonstop pain.  Last weekend I had no pain.  Oddly enough, I was out of > > town.  I kept thinking to myself what was different.  I realized that > > I had not brought my Splenda (sugar substitute with me) and was using > > Equal and regular sugar.  Since I have been home, I have used only > > real sugar and still no pain. Coincidence?  Maybe.  But it was in > > September that I started using Splenda.  Anyone else ever have > > problems with this?  I know it is not the cause of my original > > problem, but it seems that it heightened the pain intensity and > > amount. > YES!   > I have been increasingly sick for over a year and recently > discovered that all the non-absorbable sugars tend to cause > excessive gas.  I was using Splenda almost exclusively > during this time but never put the two together. > In my case the increased gas definitely has been connected > to increased reflux.  I have stopped all artificial > sweeteners and I’m not all better, but I’m noticeably > improved. > I’ve been trying xylitol (Miracle Sweet) which comes from > Finland and is, I believe a natural and absorbable sugar.   > I think it’s ok but I’m so flared that it’s hard to tell. > My gastro (AFTER I found out about the artificial > sweeteners), also told me that some people have trouble > with the sugars in milk products as well. > Keep us posted as to how you’re doing and what you’ve > found.   > Louise > hi louise! > thanks for your input.  10 days splenda free and there is a major > difference.  like i said, it wasn’t what caused years of reflux, but > what has amazed me is how i have controlled my diet so well and still > had horrible problems while i was using splenda.  if i had eaten this > way before, i would never have had a problem.  this body hasn’t seen a > margarita or mexican food for 4 months now…no sodas, fried foods, > fatty foods etc.  i eat small amounts intentionally avoiding that

 hi, I assume that you do know about the "standard" no-no foods such as carbonated beverages, chocolate, alcohol, mint, and for me, definitely garlic and onions.  I also discovered that the menthol in cough drops is a peppermint based substance and should be avoided. Do you find that gas builds up when you have the worst reflux? Louise —

Response:

Propulsid???

Question:

My doctor has suggested I try to get ahold of some propulsid or cisapride, which next I travel, which I do quite regularly. In which countris is propulsid or cisapride legal to be sold? Thanks. —

Response:

> My doctor has suggested I try to get ahold of some > propulsid or cisapride, which next I travel, which I do > quite regularly.

Are you sure?  Propulsid has some pretty serious risks and contraindications. — Richard W Kaszeta http://www.kaszeta.org/rich

Response:

> > My doctor has suggested I try to get ahold of some > propulsid or cisapride, which next I travel, which I do > quite regularly. > Are you sure?  Propulsid has some pretty serious risks and contraindications.

I’m sure he told me to….  He did have me get an EKG first to verify that my QT level (whatever that is), was within normal limits. But I’m not sure I should do it although I’m having a pretty bad time with reflux and throat problems even at 60mg of Prevacid per day and pretty rigorous dietary controls, bed raised etc. He led me to believe that it is legal and accepted medical practice in most countries, save the US and Canada.  I know it’s available in Mexico but I’m wondering if anyone knows what other countries consider it safe.  How about western Europe for example? I’m not sure at all – but it’s very tempting and I don’t know who to trust. Louise —

Response:

– Hide quoted text — Show quoted text -> > My doctor has suggested I try to get ahold of some > > propulsid or cisapride, which next I travel, which I do > > quite regularly. > Are you sure?  Propulsid has some pretty serious risks and contraindications. > I’m sure he told me to….  He did have me get an EKG first > to verify that my QT level (whatever that is), was within > normal limits. > But I’m not sure I should do it although I’m having a > pretty bad time with reflux and throat problems even at > 60mg of Prevacid per day and pretty rigorous dietary > controls, bed raised etc. > He led me to believe that it is legal and accepted medical > practice in most countries, save the US and Canada.  I know > it’s available in Mexico but I’m wondering if anyone knows > what other countries consider it safe.  How about western > Europe for example? > I’m not sure at all – but it’s very tempting and I don’t > know who to trust.

Prokinetic agents like propulsid or metaclopramide (Reglan) aid in esophageal clearing of reflux. They are best used in conjunction with anti-secretory drugs like Nexium. The difference between Propulsid (which is off the market in the US) and Reglan are not that great in practical use. If Reglan doesn’t help you for whatever your problem is, then I doubt the Propulsid will either. At least not enough to justify the risk or go the hassle of importing it. HMc

Response:

> Prokinetic agents like propulsid or metaclopramide (Reglan) aid in > esophageal clearing of reflux. They are best used in conjunction with > anti-secretory drugs like Nexium. The difference between Propulsid (which is > off the market in the US) and Reglan are not that great in practical use. If > Reglan doesn’t help you for whatever your problem is, then I doubt the > Propulsid will either. At least not enough to justify the risk or go the > hassle of importing it. > HMc

Reglan does have some nasty psychological side-effects in some people though. My gastro sited that 15% of those who take reglan will develop side-effects from severe insomnia to extreme depression. It seems it also can cause parkinsons like symptoms… "Reglan is a neuroleptic medication used to treat gastrointestinal problems that have had many cases of Tardive Dyskinesia reported in response to it. Reglan is supposed to increase the stomach and small intestine contractions to help the passage of food. As every medication, Reglan has side effects associated to it and some of them are very serious. In February 1996, the FDA warned that Reglan causes an increased risk of Parkinsonism. Reglan can also cause people to have mild to severe depression, so patients that already suffer depression may want to consider an alternate treatment plan to Reglan. Tardive Dyskinesia has been most often linked to the use of antipsychotic drugs, but the potentially permanent muscle disorder has also been reported side effects of Reglan. Especially older Reglan patients should first consider the risks and benefits of Reglan since elders have a higher incidence of suffering Tardive Dyskinesia." http://www.tardive-dyskinesia.com/reglan/

Response:

> My doctor has suggested I try to get ahold of some > propulsid or cisapride, which next I travel, which I do > quite regularly. > In which countris is propulsid or cisapride legal to be > sold? > Thanks.

Does your doctor know that there is a limited access program for propulsid? The prescription medication PROPULSID

GERD incidence rates for various countries?

Esomeprazole is a medication used to treat gestational acid reflux disease (GERD). Buy esomeprazole tablets and feel better today!

Question:

> Mark, everbody is completely well, right up until the day they get sick… > The mechanism behind TILESR’s is that the LES inappropriately get a signal > to relax. There are several things that can initiate this. Most frequent is > simply a full stomach. There are some foods/substances that can cause this > such as nicotine, alcohol, caffiene, and some spices. There is some > speculation that it can be induced by stress, but this link has not been > demonstrated. > The cause? It just happens. Some people are genetically prone to it. In your > case, I would suspect that GERD runs in the family. > HMc

Thanks again. It seems your suspicions could be correct… I just spoke with my father and found out that he has had GERD for a while. I always remembered him popping a lot of Antacids when I was a kid but I never made the connection. thanks for the insight. Mark

Response:

> It seems your suspicions could be correct… > I just spoke with my father and found out that he has had GERD for a > while. > I always remembered him popping a lot of Antacids when I was a kid but > I never made the connection.

Indeed, like a lot of medical conditions, people may have had problems in your family for years, but it was never diagnosed.  While nobody in my family had ever had heard of "GERD", quite a few of my relatives have had chronic "heartburn." That, and sometimes people don’t talk about their medical problems, even to relatives.  A friend of mine came down with Crohn’s disease, and only after the diagnosis and surgery did she discover that her father and grandfather both had the same disease (although neither of them had required surgery).  And I didn’t find out that red-green colorblindness ran in my mother’s family (or that I had it myself) until I had my medical exam for the Naval Academy, which rather put a damper on things… (yes, you can get quite far in life before you realize that you are red-green colorblind). — Richard W Kaszeta http://www.kaszeta.org/rich

Response:

– Hide quoted text — Show quoted text -> Thanks for the reply. I had not considered the link between obesity > and Gerd as I am not overweight (probably closer to underweight) > So what originally causes the lower esophageal sphincter to not > function correctly? > It seems strange to me that all of a sudden one’s LES can stop working > correctly (as was the case with me…out of the blue one day a year > ago) > In my case, I am not overweight. I am realtively young(23). I do not > smoke or drink. I never eat fast food, or fatty foods. I dont eat > chocolate…or candy…etc The only meats that I eat are chicken and > fish. > but…I have had problems with stress in the past. > Is it possible for stress alone  to cause the LES to not function > correctly?

Mark, everbody is completely well, right up until the day they get sick… The mechanism behind TILESR’s is that the LES inappropriately get a signal to relax. There are several things that can initiate this. Most frequent is simply a full stomach. There are some foods/substances that can cause this such as nicotine, alcohol, caffiene, and some spices. There is some speculation that it can be induced by stress, but this link has not been demonstrated. The cause? It just happens. Some people are genetically prone to it. In your case, I would suspect that GERD runs in the family. HMc

Response:

– Hide quoted text — Show quoted text ->The mechanism behind TILESR’s is that the LES inappropriately get a signal >to relax. There are several things that can initiate this. Most frequent is >simply a full stomach. There are some foods/substances that can cause this >such as nicotine, alcohol, caffiene, and some spices. There is some >speculation that it can be induced by stress, but this link has not been >demonstrated. >The cause? It just happens. Some people are genetically prone to it. In your >case, I would suspect that GERD runs in the family. > A hiatal hernia will exaggerate them, also.

Actually, a hiatus hernia would affect LES resting pressure, but usually wouldn’t contribute to inappropriate LES relaxation. The latter are neurally mediated. Here are the basics: The LES is the barrier between the stomach and esophagus. Reflux occurs when intragastric pressure exceeds intraesophageal pressure, and when that pressure gradient is greater than the pressure of the LES. Therefore, anything that increases that gradient might promote reflux. Also, anything that causes lower pressure in the LES would facilitate reflux (at lower pressure gradients). Obese people (and pregnant people) have higher intrabdominal pressure due to the intrabdominal fat (baby), so that gradient is greater, more likely to exceed the LES pressure and cause reflux. That intrabdominal pressure goes even higher when that person bends over. When lying down, gravity now has no contribution to the pressure gradient. So reflux is more common when lying down, or when bending over. Additionally, some people (fat or thin) have a low LES resting pressure, so that pressure gradient between stomach and esophagus needs to be less for reflux to occur. And, some people have more active transient LES relaxation in response to full stomach, nicotine, alcohol etc. So, you could be a thin person, but have a low LES resting pressure (such as with hiatus hernia), or very active TLESR’s and get bad reflux. It is more common in obese people because of their higher intrabdominal pressure. And, it’s also true that the intrabdominal fat can push upward and aggravate a tendency to hiatus hernia, which in turn can lead to lower LES pressure, which in turn can lead to reflux. So, how do we cure GERD? (CURE, not just treat the symptoms with prilosec). We either have to lower intrabdominal pressure, increase LES pressure, or stop the TLESR’s. Or any combination of the three. If an obese person with GERD loses a lot of weight, their intrabdominal pressure goes down and their GERD will very likely go away. This is one reason why obesity surgery cures GERD. If a person with GERD has a Nissen fundoplication, that will increase the resting LES pressure and splint its relaxations, and GERD is cured. If a person with GERD has a Stretta procedure, that will increase LES pressure, AND it will ablate afferent nerve fibers that contribute to TLESR’s, and the GERD is cured. Medical antisecretory treatment only decreases the amount of acid present in the stomach. It doesn’t stop the reflux. In fact, reflux still occurs, but the refluxate is highly alkaline. This alkaline reflux doesn’t cause symptoms, but still has the capacity to severely damage the esophagus over time (Barrett’s esophagus). Medical treatment may very well not do anything to lower the risk of esophageal cancer. As I have said before, symptom management with antisecretory medication may be entirely appropriate if it   a) controls the symptoms to the patient’s satisfaction, and     b) there is not evidence of  Barrett’s esophagus. HMc

Response:

- Hide quoted text — Show quoted text – > Obesity is a very substantial contributing factor to GERD. Since obesity is > so rampantly epidemic here in the US, it’s not surprising that GERD is too. > Likewise, there is some correlation between lower incidence of GERD and > lower incidence of obesity in countries where the amount and type of food is > less obesity-inducing. > Diet does not cause GERD. GERD is caused by a dysfunctional lower esophageal > sphincter. That dysfunction causing reflux symptoms is exacerbated by the > increased intraabdominal pressure associated with obesity. > So, to the extent that diet contributes to obesity, GERD is indeed > diet -associated, and the classic American diet definitely makes it more > common in the US. > HMc

Thanks for the reply. I had not considered the link between obesity and Gerd as I am not overweight (probably closer to underweight) So what originally causes the lower esophageal sphincter to not function correctly? It seems strange to me that all of a sudden one’s LES can stop working correctly (as was the case with me…out of the blue one day a year ago) In my case, I am not overweight. I am realtively young(23). I do not smoke or drink. I never eat fast food, or fatty foods. I dont eat chocolate…or candy…etc The only meats that I eat are chicken and fish. but…I have had problems with stress in the past. Is it possible for stress alone  to cause the LES to not function correctly? thanks, Mark

Response:

Does anyone have any info on what countries have what incidence rates for GERD (not sure if I am wording this correctly). I remember reading somewhere that in Africa for instance GERD is pretty rare… It would be interesting to take a look at countries where GERD is relatively rare, and see if the native diet has anything to do with it… Mark

Response:

> Does anyone have any info on what countries have what incidence rates > for GERD (not sure if I am wording this correctly). I remember reading > somewhere that in Africa for instance GERD is pretty rare… > It would be interesting to take a look at countries where GERD is > relatively rare, and see if the native diet has anything to do with > it…

Obesity is a very substantial contributing factor to GERD. Since obesity is so rampantly epidemic here in the US, it’s not surprising that GERD is too. Likewise, there is some correlation between lower incidence of GERD and lower incidence of obesity in countries where the amount and type of food is less obesity-inducing. Diet does not cause GERD. GERD is caused by a dysfunctional lower esophageal sphincter. That dysfunction causing reflux symptoms is exacerbated by the increased intraabdominal pressure associated with obesity. So, to the extent that diet contributes to obesity, GERD is indeed diet -associated, and the classic American diet definitely makes it more common in the US. HMc

Response:

Fundamental indigestion

Rabeprazole is a medication used to treat gestational acid reflux disease (GERD) and ulcers. Buy rabeprazole tablets and feel better today!

Question:

Would it seem reasonable for a consultant to diagnose (prior to future tests) fundamental indigestion for an elderly  patient (68) who last year had treatment for a duodenal ulcer and whose symptoms keep returning  after having had triple therapy and when PPI’s are reduced to a maintenance level for acid reflux. Grisby

Response:

> Would it seem reasonable for a consultant to diagnose (prior to future > tests) fundamental indigestion for an elderly  patient (68) who last year > had treatment for a duodenal ulcer and whose symptoms keep returning after > having had triple therapy and when PPI’s are reduced to a maintenance level > for acid reflux. > Grisby

I’m not sure what "fundamental indigestion" is. If one is working up dyspeptic symptoms, then I don’t think it’s reasonable to assume any diagnosis until the workup is complete. This would include EGD, gallbladder ultrasound, HIDA scan with ejection fraction of the gallbladder (if ultrasound is normal), esophageal pH testing, and esophageal manometry. If "fundamental indigestion" is what would be normally termed a "functional" diagnosis, then it’s a diagnosis of exclusion and by definition can’t be made until a complete workup is done. HMc – Hide quoted text — Show quoted text –

Response:

– Hide quoted text — Show quoted text -> Would it seem reasonable for a consultant to diagnose (prior to future > tests) fundamental indigestion for an elderly  patient (68) who last year > had treatment for a duodenal ulcer and whose symptoms keep returning > after > having had triple therapy and when PPI’s are reduced to a maintenance > level > for acid reflux. > Grisby > I’m not sure what "fundamental indigestion" is. > If one is working up dyspeptic symptoms, then I don’t think it’s reasonable > to assume any diagnosis until the workup is complete. This would include > EGD, gallbladder ultrasound, HIDA scan with ejection fraction of the > gallbladder (if ultrasound is normal), esophageal pH testing, and esophageal > manometry. > If "fundamental indigestion" is what would be normally termed a "functional" > diagnosis, then it’s a diagnosis of exclusion and by definition can’t be > made until a complete workup is done. > HMc

Sorry I got the wording wrong it should have been Functional Dyspepsia. Grisby Functional dyspepsia (FD) is defined as chronic upper, centered abdominal discomfort or pain excluding the predominant symptom, heartburn. Associated symptoms are early satiety, nausea, vomiting, abdominal distension, bloating, and anorexia. For many years motor (movement) abnormalities in the stomach have been investigated and thought to be the cause of FD. As usual, psychosomatic theories are popular and patients are often prescribed tranquilizers or antidepressants.  Stress and anxiety are linked to motility problems and with the blind of a blind eye; a bad theory of FD (and IBS) was formulated and has remained popular despite lack of any convincing evidence. FD suffers responds poorly to common drug therapies and the majority of sufferers have episodic symptoms that reduce the quality of life and result in increased use of healthcare resources. Since FD is a rather vague diagnosis, symptoms often overlap with peptic ulcers, esophagitis and irritable bowel syndrome. It is easy to confuse acid reflux into the esophagus (GERD) with FD. Most gastroenterologists will not classify heartburn as "dyspepsia", and if esophagitis is present, FD cannot be diagnosed. By strict definition, patients with FD have undergone upper intestinal endoscopy that has revealed no lesions that can explain their symptoms. Diagnosis should include testing and possibly treatment for Helicobacter pylori. If infection is present, antisecretory therapy with H2-receptor antagonists or proton-pump inhibitors can be tried but these therapies are often not effective. One has to recall that H Pylori is often found in asymptomatic patients and their presence does not automatically mean that they are the cause of disease.

Response:

– Hide quoted text — Show quoted text -> > Would it seem reasonable for a consultant to diagnose (prior to future > > tests) fundamental indigestion for an elderly  patient (68) who last > year > > had treatment for a duodenal ulcer and whose symptoms keep returning > after > > having had triple therapy and when PPI’s are reduced to a maintenance > level > > for acid reflux. > > Grisby > I’m not sure what "fundamental indigestion" is. > If one is working up dyspeptic symptoms, then I don’t think it’s > reasonable > to assume any diagnosis until the workup is complete. This would include > EGD, gallbladder ultrasound, HIDA scan with ejection fraction of the > gallbladder (if ultrasound is normal), esophageal pH testing, and > esophageal > manometry. > If "fundamental indigestion" is what would be normally termed a > "functional" > diagnosis, then it’s a diagnosis of exclusion and by definition can’t be > made until a complete workup is done. > HMc > Sorry I got the wording wrong it should have been Functional Dyspepsia. > Grisby > Functional dyspepsia (FD) is defined as chronic upper, centered abdominal > discomfort or pain excluding the predominant symptom, heartburn. Associated > symptoms are early satiety, nausea, vomiting, abdominal distension, > bloating, and anorexia. For many years motor (movement) abnormalities in the > stomach have been investigated and thought to be the cause of FD. As usual, > psychosomatic theories are popular and patients are often prescribed > tranquilizers or antidepressants.  Stress and anxiety are linked to motility > problems and with the blind of a blind eye; a bad theory of FD (and IBS) was > formulated and has remained popular despite lack of any convincing evidence. > FD suffers responds poorly to common drug therapies and the majority of > sufferers have episodic symptoms that reduce the quality of life and result > in increased use of healthcare resources. > Since FD is a rather vague diagnosis, symptoms often overlap with peptic > ulcers, esophagitis and irritable bowel syndrome. It is easy to confuse acid > reflux into the esophagus (GERD) with FD. Most gastroenterologists will not > classify heartburn as "dyspepsia", and if esophagitis is present, FD cannot > be diagnosed. By strict definition, patients with FD have undergone upper > intestinal endoscopy that has revealed no lesions that can explain their > symptoms. Diagnosis should include testing and possibly treatment for > Helicobacter pylori. If infection is present, antisecretory therapy with > H2-receptor antagonists or proton-pump inhibitors can be tried but these > therapies are often not effective. One has to recall that H Pylori is often > found in asymptomatic patients and their presence does not automatically > mean that they are the cause of disease.

Yes, I understand the term "functional dyspepsia". It is typically a "wastebasket" diagnosis that is made after all other potential diagnoses are ruled out. Symptomatic gallbladder disease, peptic ulcer, gastritis, GERD, IBS, etc can all present with the same or similar patient complaints. As I said, a diagnosis of exclusion. EGD is commonly done as part of the workup, and GERD is one diagnosis that must be excluded. The problem is (and many physicians don’t understand this) that GERD cannot be ruled out on the basis of EGD alone since severe symptomatic reflux can most definitely be present even in the face of a completely normal EGD. EGD can only diagnose the *complications* of GERD (esophagitis, stricture, Barrett’s esophagus). A normal EGD does not rule out the GERD. Ambulatory pH testing is the only way to definitively diagnose GERD if the EGD does not demonstrate the above complications. HMc

Response:

Moderate Hiatal Hernia

Question:

Howard…. could you please explain what is meant by moderate? It’s been a month since my EGD and I’m not feeling much relief from the Nexium. How long should I wait for a return visit with my doctor? Any help would be greatly appreciated.

Response:

> Howard…. could you please explain what is meant by moderate? It’s been a > month since my EGD and I’m not feeling much relief from the Nexium. How long > should I wait for a return visit with my doctor? Any help would be greatly > appreciated.

A hiatus hernia is where the upper part of the stomach can slip or has slipped up into the chest. The part that slips includes the gastroesophageal junction and the lower esophageal sphincter. A "moderate" hiatus hernia is one where the gastroesophageal junction is displaced about 2-3 centimeters upward into the chest. It is a common misconception, even among doctors, that a hiatus hernia and acid reflux are the same thing. "Doctor, I have terrible heartburn"…."Yes, you must have a hiatus hernia."    Baloney. Many people with hiatus hernia have no acid reflux, and many people with acid reflux have no hiatus hernia. The causative factor in GERD is dysfunction of the lower esophageal sphincter. In about 40% of cases, the main reason for LES dysfunction is low resting pressure. In SOME of those cases, hiatus hernia contributes to that low resting pressure, therefore, hiatus hernia might contribute to GERD in some cases. The erroneous belief in the relationship of hiatus hernia severity to GERD severity is a holdover from the old days when doctors thought, erroneously, that low LES pressure was the cause of GERD. However, in over 60% of cases of acid reflux, the main cause is transient lower esophageal sphincter relaxation. The cause of these TLESR’s are primarily such things as nicotine, alcohol, caffiene, full stomach, and some foods such as tomatoes and other spices. It’s amazing to me how few doctors understand this concept. I guess it’s just easier to tell the patient "Oh, it’s just your hiatus hernia acting up…take these pills" So, whether or not someone has a hiatus hernia is pretty much irrelevant to GERD. The problem is the function of the LES, which is the root cause of GERD. If you have acid reflux, the place to start is lifestyle modification (diet, weight loss, smaller meals etc etc….these will help control your LES dysfunction. You can also take anti-secretory medication. These meds will not fix your LES dysfunction, nor will they do anything for your hiatus hernia, but they will decrease the amount of acid in the stuff that you reflux thereby moderating your symptoms. Maybe…unless the LES dysfunction is too severe. If these things don’t work, then the function of your Lower Esophageal Sphincter needs to be addressed surgically. Bottom line….don’t worry about your hiatus hernia, worry about controlling your acid reflux. Just because you have one doesn’t imply anything about the severity of your GERD. A high DeMeester score (>14.7) or refluxing more than about 3% of the time on 48 hour pH testing, that means something. A LES resting pressure less than 10 mmHg on manometry, that means something. An EGD that shows erosive esophagitis, stricture, or Barrett’s esophagus, that means something. All of these things allow us to draw real conclusions about your reflux disease. The presence or absence of a hiatus hernia tells us virtually nothing. If you haven’t had 48 hour ambulatory pH testing or esophageal manometry, and if all the doctor saw at EGD was a "moderate" hiatus hernia, then we still have virtually no objective information about whether or not you have GERD. HMc

Response:

Aetna wants me to try protonix?

Question:

I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a new plan wants me to try a cheaper alternetive-protonix. Does anyone have experience with this?How similar/disimilar are they? Aetne wants to spend less, but will step me up only if protonix doesnt do a good job….thanks in advance…ED

Response:

> I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a > new plan wants me to try a cheaper alternetive-protonix. Does anyone > have experience with this?How similar/disimilar are they? > Aetne wants to spend less, but will step me up only if protonix doesnt > do a good job….thanks in advance…ED

It’s a common insurance company maneuver. All insurance companies negotiate deals with drug companies, and it sounds like Aetna just negotiated a better deal with Wyeth Pharmaceuticals than they had with Astra Zeneca. Protonix is fine. Different people respond to different medications differently. For some people, Nexium doesn’t work worth a damn and Protonix is their salvation. And the opposite is true too. Give the Protonix a try, see if it works ok for you. If not, your doctor will write a strongly worded letter to Aetna certifying that Protonix doesn’t work for you and you’ll get Nexium.   Probably. HMc

Response:

> I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a > new plan wants me to try a cheaper alternetive-protonix. Does anyone > have experience with this?How similar/disimilar are they?

Ahh, welcome to modern prescription coverage.  Due to changing carriers I had to move from prevacid->prilosec->protonix->nexium. For the most part, they’re the same, although the latter three seemed to work a bit better than prevacid for me, but everyone is different. Chances are, Protonix will treat you similarly to Nexium, but if it doesn’t work out, like Howard says you can usually get your doctor to talk to the insurance company and okay Nexium (but be prepared for a larger copay). Note that it’s worth checking out the OTC availability, since sometimes the OTC stuff can be cheaper than the prescription copay, although this widely varies (for a while I was taking Zantac, and OTC generic Zantac (ranitidine) from Walmart was *way* cheaper than my $15 copay at the time), since at least one proton pump inhibitor is on the market now (Prilosec OTC).  But check with your doctor before doing any drastic changes… — Richard W Kaszeta http://www.kaszeta.org/rich

Response:

– Hide quoted text — Show quoted text -> I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a > new plan wants me to try a cheaper alternetive-protonix. Does anyone > have experience with this?How similar/disimilar are they? > Aetne wants to spend less, but will step me up only if protonix doesnt > do a good job….thanks in advance…ED > It’s a common insurance company maneuver. All insurance companies negotiate > deals with drug companies, and it sounds like Aetna just negotiated a better > deal with Wyeth Pharmaceuticals than they had with Astra Zeneca. > Protonix is fine. Different people respond to different medications > differently. For some people, Nexium doesn’t work worth a damn and Protonix > is their salvation. And the opposite is true too. > Give the Protonix a try, see if it works ok for you. If not, your doctor > will write a strongly worded letter to Aetna certifying that Protonix > doesn’t work for you and you’ll get Nexium.   Probably. > HMc

Howard, I know that nexium and protonix are needed for alot of people. Isnt it some potent stuff though?

Response:

My prilosec seems to work fine for my acid but I still have stomach pain. Can’t wait for the endeoscopy. OH JOY!

– Hide quoted text — Show quoted text -> I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a > new plan wants me to try a cheaper alternetive-protonix. Does anyone > have experience with this?How similar/disimilar are they? > Ahh, welcome to modern prescription coverage.  Due to changing > carriers I had to move from prevacid->prilosec->protonix->nexium. > For the most part, they’re the same, although the latter three seemed > to work a bit better than prevacid for me, but everyone is different. > Chances are, Protonix will treat you similarly to Nexium, but if it > doesn’t work out, like Howard says you can usually get your doctor to > talk to the insurance company and okay Nexium (but be prepared for a > larger copay). > Note that it’s worth checking out the OTC availability, since > sometimes the OTC stuff can be cheaper than the prescription copay, > although this widely varies (for a while I was taking Zantac, and OTC > generic Zantac (ranitidine) from Walmart was *way* cheaper than my $15 > copay at the time), since at least one proton pump inhibitor is on the > market now (Prilosec OTC).  But check with your doctor before doing > any drastic changes… > — > Richard W Kaszeta > http://www.kaszeta.org/rich

Response:

– Hide quoted text — Show quoted text -> > I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a > > new plan wants me to try a cheaper alternetive-protonix. Does anyone > > have experience with this?How similar/disimilar are they? > > Aetne wants to spend less, but will step me up only if protonix doesnt > > do a good job….thanks in advance…ED > It’s a common insurance company maneuver. All insurance companies > negotiate > deals with drug companies, and it sounds like Aetna just negotiated a > better > deal with Wyeth Pharmaceuticals than they had with Astra Zeneca. > Protonix is fine. Different people respond to different medications > differently. For some people, Nexium doesn’t work worth a damn and > Protonix > is their salvation. And the opposite is true too. > Give the Protonix a try, see if it works ok for you. If not, your doctor > will write a strongly worded letter to Aetna certifying that Protonix > doesn’t work for you and you’ll get Nexium.   Probably. > HMc > Howard, I know that nexium and protonix are needed for alot of people. Isnt > it some potent stuff though?

The entire class of drugs, proton pump inhibitors, is VERY effective at controlling stomach acid output. HMc

Response:

– Hide quoted text — Show quoted text -> > > I’ve been on nexium .40 mg for 1 1/2 yrs now and its amazing.but now a > > > new plan wants me to try a cheaper alternetive-protonix. Does anyone > > > have experience with this?How similar/disimilar are they? > > > Aetne wants to spend less, but will step me up only if protonix doesnt > > > do a good job….thanks in advance…ED > > It’s a common insurance company maneuver. All insurance companies > negotiate > > deals with drug companies, and it sounds like Aetna just negotiated a > better > > deal with Wyeth Pharmaceuticals than they had with Astra Zeneca. > > Protonix is fine. Different people respond to different medications > > differently. For some people, Nexium doesn’t work worth a damn and > Protonix > > is their salvation. And the opposite is true too. > > Give the Protonix a try, see if it works ok for you. If not, your doctor > > will write a strongly worded letter to Aetna certifying that Protonix > > doesn’t work for you and you’ll get Nexium.   Probably. > > HMc > Howard, I know that nexium and protonix are needed for alot of people. > Isnt > it some potent stuff though? > The entire class of drugs, proton pump inhibitors, is VERY effective at > controlling stomach acid output. > HMc

I bet but can it be good for long term use? Can it damage the system ever if used to long?

Response:

> The entire class of drugs, proton pump inhibitors, is VERY effective at > controlling stomach acid output. > HMc > I bet but can it be good for long term use? Can it damage the system ever if > used to long?

When the class first came out (Losec — now Prilosec), it was only FDA approved for short term use as there was speculation (and no long term data) that it would increase the risk of stomach cancer. It has long been known that no stomach acid would result in higher levels of circulating gastrin because it’s acid that determines gastrin output via negative feedback. In other words, gastrin stimulates acid output and acid controls gastrin levels. So, if there is too much acid, there is no gastrin, and if there is too little acid, there is lots of gastrin. If you take these anti-acid drugs, you will have high circulating levels of gastrin. Gastrin is a trophic hormone — it stimulates the stomach lining and the speculation was that that constant stimulation would increase the risk of stomach cancer. This has not  been shown to be the case, and the FDA has approved PPIs for long term use. I have seen multiple polyps in the stomach many times in patients who have been on long term proton pump inhibitors, but biopsies always show little or no malignant potential, as far as we know. It IS speculated that the use of anti acid medications such as H2 receptor antagonists and PPIs increases the risk of esophageal cancer. The use of these medications alkalinizes the stomach, changing  the pH and allowing bile salts to come out of solution. These bile salts are highly irritating to the lining of the lower esphagus, but don’t cause the severe symptoms that acid causes. So even though a person’s heartburn symptoms go away, their risk of esophageal cancer actually increases. The point is that these medications don’t do anything to stop the reflux, they only change the character of the refluxate, and although there are fewer symptoms, the esophageal changes of Barrett’s esophagus (and it’s attendant cancer risk) actually progress more rapidly. The incidence of esophageal cancer has been increasing rapidly over the last 35 years, and the graphs coincide exactly with the discovery and increasing use of anti-secretory medications. The use of these medications only stops the SYMPTOMS of GERD, but doesn’t actually stop the reflux. Managing the symptoms might be appropriate if there is no evidence of Barrett’s esophagus on EGD, but ongoing surveillance is important because of the increased risk of esophageal cancer. HMc

Response:

Two questions. 1 Are polyps caused by propton pump inhibitors lessening the acid content of the stomach? 2 "Stomach Pain" is listed as one of the side effects of proton pump inhibitors, how does a patient know if his pain is caused by the drug instead of his ulcer or other problem? Derek.

– Hide quoted text — Show quoted text -> > The entire class of drugs, proton pump inhibitors, is VERY effective at > > controlling stomach acid output. > > HMc > I bet but can it be good for long term use? Can it damage the system ever > if > used to long? > When the class first came out (Losec — now Prilosec), it was only FDA > approved for short term use as there was speculation (and no long term data) > that it would increase the risk of stomach cancer. It has long been known > that no stomach acid would result in higher levels of circulating gastrin > because it’s acid that determines gastrin output via negative feedback. In > other words, gastrin stimulates acid output and acid controls gastrin > levels. So, if there is too much acid, there is no gastrin, and if there is > too little acid, there is lots of gastrin. If you take these anti-acid > drugs, you will have high circulating levels of gastrin. > Gastrin is a trophic hormone — it stimulates the stomach lining and the > speculation was that that constant stimulation would increase the risk of > stomach cancer. This has not  been shown to be the case, and the FDA has > approved PPIs for long term use. I have seen multiple polyps in the stomach > many times in patients who have been on long term proton pump inhibitors, > but biopsies always show little or no malignant potential, as far as we > know. > It IS speculated that the use of anti acid medications such as H2 receptor > antagonists and PPIs increases the risk of esophageal cancer. The use of > these medications alkalinizes the stomach, changing  the pH and allowing > bile salts to come out of solution. These bile salts are highly irritating > to the lining of the lower esphagus, but don’t cause the severe symptoms > that acid causes. So even though a person’s heartburn symptoms go away, > their risk of esophageal cancer actually increases. The point is that these > medications don’t do anything to stop the reflux, they only change the > character of the refluxate, and although there are fewer symptoms, the > esophageal changes of Barrett’s esophagus (and it’s attendant cancer risk) > actually progress more rapidly. The incidence of esophageal cancer has been > increasing rapidly over the last 35 years, and the graphs coincide exactly > with the discovery and increasing use of anti-secretory medications. > The use of these medications only stops the SYMPTOMS of GERD, but doesn’t > actually stop the reflux. Managing the symptoms might be appropriate if > there is no evidence of Barrett’s esophagus on EGD, but ongoing surveillance > is important because of the increased risk of esophageal cancer. > HMc

Response:

> Two questions. > 1 Are polyps caused by propton pump inhibitors lessening the acid content of > the stomach? > 2 "Stomach Pain" is listed as one of the side effects of proton pump > inhibitors, how does a patient know if his pain is caused by the drug > instead of his ulcer or other problem? > Derek.

1.  Yes. The decreased stomach acid results in higher circulating gastrin, which stimulates the polyp growth in stomach lining. 2.  It’s not classified as "stomach" pain, but as "abdominal" pain. Usually it is cramping in the small intestine or in the colon. One would sort it out by the nature of the pain, or ultimately by EGD if it could not be diagnosed clinically. HMc

Response:

> Two questions. > 1 Are polyps caused by propton pump inhibitors lessening the acid content > of > the stomach? > 2 "Stomach Pain" is listed as one of the side effects of proton pump > inhibitors, how does a patient know if his pain is caused by the drug > instead of his ulcer or other problem? > Derek. > 1.  Yes. The decreased stomach acid results in higher circulating gastrin, > which stimulates the polyp growth in stomach lining.

What is polyp growth? – Hide quoted text — Show quoted text -> 2.  It’s not classified as "stomach" pain, but as "abdominal" pain. Usually > it is cramping in the small intestine or in the colon. One would sort it out > by the nature of the pain, or ultimately by EGD if it could not be diagnosed > clinically. > HMc

Response:

– Hide quoted text — Show quoted text -> > Two questions. > > 1 Are polyps caused by propton pump inhibitors lessening the acid > content > of > > the stomach? > > 2 "Stomach Pain" is listed as one of the side effects of proton pump > > inhibitors, how does a patient know if his pain is caused by the drug > > instead of his ulcer or other problem? > > Derek. > 1.  Yes. The decreased stomach acid results in higher circulating gastrin, > which stimulates the polyp growth in stomach lining. > What is polyp growth?

Something that grows in dark, moist places and looks like a mushroom. Derek

Response:

> What is polyp growth?

Google. Or, look at http://www.endoskopischer-atlas.de/m18e.htm and at  http://tinyurl.com/rgcx . In fact, look at this guy’s whole site, it’s pretty good http://tinyurl.com/rgd1 HMc

Response:

- Hide quoted text — Show quoted text -> > The entire class of drugs, proton pump inhibitors, is VERY effective at > > controlling stomach acid output. > > HMc > I bet but can it be good for long term use? Can it damage the system ever >  if > used to long? > When the class first came out (Losec — now Prilosec), it was only FDA > approved for short term use as there was speculation (and no long term data) > that it would increase the risk of stomach cancer. It has long been known > that no stomach acid would result in higher levels of circulating gastrin > because it’s acid that determines gastrin output via negative feedback. In > other words, gastrin stimulates acid output and acid controls gastrin > levels. So, if there is too much acid, there is no gastrin, and if there is > too little acid, there is lots of gastrin. If you take these anti-acid > drugs, you will have high circulating levels of gastrin. > Gastrin is a trophic hormone — it stimulates the stomach lining and the > speculation was that that constant stimulation would increase the risk of > stomach cancer. This has not  been shown to be the case, and the FDA has > approved PPIs for long term use. I have seen multiple polyps in the stomach > many times in patients who have been on long term proton pump inhibitors, > but biopsies always show little or no malignant potential, as far as we > know. > It IS speculated that the use of anti acid medications such as H2 receptor > antagonists and PPIs increases the risk of esophageal cancer. The use of > these medications alkalinizes the stomach, changing  the pH and allowing > bile salts to come out of solution. These bile salts are highly irritating > to the lining of the lower esphagus, but don’t cause the severe symptoms > that acid causes. So even though a person’s heartburn symptoms go away, > their risk of esophageal cancer actually increases. The point is that these > medications don’t do anything to stop the reflux, they only change the > character of the refluxate, and although there are fewer symptoms, the > esophageal changes of Barrett’s esophagus (and it’s attendant cancer risk) > actually progress more rapidly. The incidence of esophageal cancer has been > increasing rapidly over the last 35 years, and the graphs coincide exactly > with the discovery and increasing use of anti-secretory medications. > The use of these medications only stops the SYMPTOMS of GERD, but doesn’t > actually stop the reflux. Managing the symptoms might be appropriate if > there is no evidence of Barrett’s esophagus on EGD, but ongoing surveillance > is important because of the increased risk of esophageal cancer. > HMc

OH MY! OH MY!  WHAT TO DO!  I am so confused.  I am taking Protonix so I don’t have acid reflux so I don’t get esophegeal cancer and long term use will likely CAUSE the cancer.  What do you suggest people with this chronic problem do exactly?  This is really perplexing.  I’d rather take no meds if given a choice.  Please tell me what to do here as I have been on Protonix for several years and am only 47.  I love my life and want to keep on livin it!  ( :  Is there anything that will actually stop the reflux…diet, etc.?

Response:

– Hide quoted text — Show quoted text -> What is polyp growth? > Google. > Or, look at http://www.endoskopischer-atlas.de/m18e.htm > and at >  http://tinyurl.com/rgcx . In fact, look at this guy’s whole site, it’s > pretty good http://tinyurl.com/rgd1 > HMc

Yuck!

Response:

– Hide quoted text — Show quoted text -> > > The entire class of drugs, proton pump inhibitors, is VERY effective at > > > controlling stomach acid output. > > > HMc > > I bet but can it be good for long term use? Can it damage the system ever >  if > > used to long? > When the class first came out (Losec — now Prilosec), it was only FDA > approved for short term use as there was speculation (and no long term data) > that it would increase the risk of stomach cancer. It has long been known > that no stomach acid would result in higher levels of circulating gastrin > because it’s acid that determines gastrin output via negative feedback. In > other words, gastrin stimulates acid output and acid controls gastrin > levels. So, if there is too much acid, there is no gastrin, and if there is > too little acid, there is lots of gastrin. If you take these anti-acid > drugs, you will have high circulating levels of gastrin. > Gastrin is a trophic hormone — it stimulates the stomach lining and the > speculation was that that constant stimulation would increase the risk of > stomach cancer. This has not  been shown to be the case, and the FDA has > approved PPIs for long term use. I have seen multiple polyps in the stomach > many times in patients who have been on long term proton pump inhibitors, > but biopsies always show little or no malignant potential, as far as we > know. > It IS speculated that the use of anti acid medications such as H2 receptor > antagonists and PPIs increases the risk of esophageal cancer. The use of > these medications alkalinizes the stomach, changing  the pH and allowing > bile salts to come out of solution. These bile salts are highly irritating > to the lining of the lower esphagus, but don’t cause the severe symptoms > that acid causes. So even though a person’s heartburn symptoms go away, > their risk of esophageal cancer actually increases. The point is that these > medications don’t do anything to stop the reflux, they only change the > character of the refluxate, and although there are fewer symptoms, the > esophageal changes of Barrett’s esophagus (and it’s attendant cancer risk) > actually progress more rapidly. The incidence of esophageal cancer has been > increasing rapidly over the last 35 years, and the graphs coincide exactly > with the discovery and increasing use of anti-secretory medications. > The use of these medications only stops the SYMPTOMS of GERD, but doesn’t > actually stop the reflux. Managing the symptoms might be appropriate if > there is no evidence of Barrett’s esophagus on EGD, but ongoing surveillance > is important because of the increased risk of esophageal cancer. > HMc > OH MY! OH MY!  WHAT TO DO!  I am so confused.  I am taking Protonix so > I don’t have acid reflux so I don’t get esophegeal cancer and long > term use will likely CAUSE the cancer.  What do you suggest people > with this chronic problem do exactly?  This is really perplexing.  I’d > rather take no meds if given a choice.  Please tell me what to do here > as I have been on Protonix for several years and am only 47.  I love > my life and want to keep on livin it!  ( :  Is there anything that > will actually stop the reflux…diet, etc.?

I confess that the relationship of long term anti-secretory medication to esophageal cancer is a little controversial in the medical world, but the mounting evidence is compelling. The situation is not dissimilar to the relationship of smoking to lung cancer. Many physicians fought the concept that those two things might be related for many years. The base reasons are the same — chronic irritation of the bronchial tree and chronic irritation of the lower esophagus. Personally, I think the evidence supporting the relationship of anti-secretory medication to Barrett’s esophagus and esophageal cancer is compelling as do the majority of physicians that deal with these issues on a daily basis. You may remember an advertising campaign by RJ Reynolds Tobacco in the 50s that featured TV and print ads focused on doctors smoking cigarrettes while relaxing. You are unlikely to see those ads again anytime soon. If your symptoms are under good control ie. medication, lifestyle changes, and watching your diet are controlling your reflux symptoms to your satisfaction, then nothing needs to be done UNLESS your EGD shows evidence of esophageal damage from the reflux. If you have an EGD which shows inflammation, stricture, or Barrett’s esophagus, then it is time to consider surgical intervention. Chronic relux sufferers need to have periodic EGD to evaluate the lower esophagus. Every 2-4 years depending on findings. If you haven’t had one, you need one. Medication and lifestyle changes only control the SYMPTOMS of reflux. Those things do nothing to address the CAUSE of the relux, that being dysfunction of the lower esophageal sphincter. The only way reflux can be stopped is with surgery. State-of-the-art in that regard is either a Nissen laparoscopic gastric fundoplication (look at http://tinyurl.com/rkvi ) or the Stretta procedure (look at http://tinyurl.com/rkvn ). Both are, or can be, effective anti-reflux treatments that can CURE acid reflux, not just manage the symptoms. HMc

Response:

howard!  you are such a wealth of knowledge and so wonderful to give of your time so freely here.  i would love your take on this situation.  by the way i am waiting for my appointment with a gastro….can’t get in until nov. 25th.  i know it’s a long wait but my internist and i agree that there is no crisis here and he is the one i want to see.  i have been on protonix off and on for a couple of years and have never treated my reflux very seriously until recently. it seems that when my diet gets crazy i start thinking the protonix isn’t working and have twice tried other drugs.  i had the same result with nexium and prilosec.  after a couple days i was elated.  it seemed that i could have my margaritas and mexican food and get by with no acid reflux.  i felt like a criminal getting by with the crime.  well, within about 7-10 days i would feel like there was a big lump in my diaphram and that i couldn’t belch to save my life.  it was like there was no digestion going on whatsoever.  the feeling was worse to me than the actual acid reflux and pain/pressure i had experienced in the past.  once i would stop the new drug, that problem would resolve within a couple of days and i would get back on the protonix.  i am now diligently keeping a food diary and being very good about my diet.  i am losing weight because i am eating smaller portions.  i have also elevated my bed.  things are soooo much better now.  i am just curious if you have heard of others having that experience with those meds?  thanks again for sharing your time and knowledge with all of us here….guess we are all a mess!

Response:

– Hide quoted text — Show quoted text -> > > > The entire class of drugs, proton pump inhibitors, is VERY effective > at > > > > controlling stomach acid output. > > > > HMc > > > I bet but can it be good for long term use? Can it damage the system > ever > >  if > > > used to long? > > When the class first came out (Losec — now Prilosec), it was only FDA > > approved for short term use as there was speculation (and no long term > data) > > that it would increase the risk of stomach cancer. It has long been > known > > that no stomach acid would result in higher levels of circulating > gastrin > > because it’s acid that determines gastrin output via negative feedback. > In > > other words, gastrin stimulates acid output and acid controls gastrin > > levels. So, if there is too much acid, there is no gastrin, and if there > is > > too little acid, there is lots of gastrin. If you take these anti-acid > > drugs, you will have high circulating levels of gastrin. > > Gastrin is a trophic hormone — it stimulates the stomach lining and the > > speculation was that that constant stimulation would increase the risk > of > > stomach cancer. This has not  been shown to be the case, and the FDA has > > approved PPIs for long term use. I have seen multiple polyps in the > stomach > > many times in patients who have been on long term proton pump > inhibitors, > > but biopsies always show little or no malignant potential, as far as we > > know. > > It IS speculated that the use of anti acid medications such as H2 > receptor > > antagonists and PPIs increases the risk of esophageal cancer. The use of > > these medications alkalinizes the stomach, changing  the pH and allowing > > bile salts to come out of solution. These bile salts are highly > irritating > > to the lining of the lower esphagus, but don’t cause the severe symptoms > > that acid causes. So even though a person’s heartburn symptoms go away, > > their risk of esophageal cancer actually increases. The point is that > these > > medications don’t do anything to stop the reflux, they only change the > > character of the refluxate, and although there are fewer symptoms, the > > esophageal changes of Barrett’s esophagus (and it’s attendant cancer > risk) > > actually progress more rapidly. The incidence of esophageal cancer has > been > > increasing rapidly over the last 35 years, and the graphs coincide > exactly > > with the discovery and increasing use of anti-secretory medications. > > The use of these medications only stops the SYMPTOMS of GERD, but > doesn’t > > actually stop the reflux. Managing the symptoms might be appropriate if > > there is no evidence of Barrett’s esophagus on EGD, but ongoing > surveillance > > is important because of the increased risk of esophageal cancer. > > HMc > OH MY! OH MY!  WHAT TO DO!  I am so confused.  I am taking Protonix so > I don’t have acid reflux so I don’t get esophegeal cancer and long > term use will likely CAUSE the cancer.  What do you suggest people > with this chronic problem do exactly?  This is really perplexing.  I’d > rather take no meds if given a choice.  Please tell me what to do here > as I have been on Protonix for several years and am only 47.  I love > my life and want to keep on livin it!  ( :  Is there anything that > will actually stop the reflux…diet, etc.? > I confess that the relationship of long term anti-secretory medication to > esophageal cancer is a little controversial in the medical world, but the > mounting evidence is compelling. The situation is not dissimilar to the > relationship of smoking to lung cancer. Many physicians fought the concept > that those two things might be related for many years. The base reasons are > the same — chronic irritation of the bronchial tree and chronic irritation > of the lower esophagus. Personally, I think the evidence supporting the > relationship of anti-secretory medication to Barrett’s esophagus and > esophageal cancer is compelling as do the majority of physicians that deal > with these issues on a daily basis. You may remember an advertising campaign > by RJ Reynolds Tobacco in the 50s that featured TV and print ads focused on > doctors smoking cigarrettes while relaxing. You are unlikely to see those > ads again anytime soon. > If your symptoms are under good control ie. medication, lifestyle changes, > and watching your diet are controlling your reflux symptoms to your > satisfaction, then nothing needs to be done UNLESS your EGD shows evidence > of esophageal damage from the reflux. If you have an EGD which shows > inflammation, stricture, or Barrett’s esophagus, then it is time to consider > surgical intervention. > Chronic relux sufferers need to have periodic EGD to evaluate the lower > esophagus. Every 2-4 years depending on findings. If you haven’t had one, > you need one. > Medication and lifestyle changes only control the SYMPTOMS of reflux. Those > things do nothing to address the CAUSE of the relux, that being dysfunction > of the lower esophageal sphincter. The only way reflux can be stopped is > with surgery. State-of-the-art in that regard is either a Nissen > laparoscopic gastric fundoplication (look at http://tinyurl.com/rkvi ) or > the Stretta procedure (look at http://tinyurl.com/rkvn ). Both are, or can > be, effective anti-reflux treatments that can CURE acid reflux, not just > manage the symptoms. > HMc

I would like to add to this Howard with your aproval. A healthy diet itself can decrease chances of cancer with the right amount of antioxidents and greens as well correct?

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– Hide quoted text — Show quoted text -> howard!  you are such a wealth of knowledge and so wonderful to give > of your time so freely here.  i would love your take on this > situation.  by the way i am waiting for my appointment with a > gastro….can’t get in until nov. 25th.  i know it’s a long wait but > my internist and i agree that there is no crisis here and he is the > one i want to see.  i have been on protonix off and on for a couple of > years and have never treated my reflux very seriously until recently. > it seems that when my diet gets crazy i start thinking the protonix > isn’t working and have twice tried other drugs.  i had the same result > with nexium and prilosec.  after a couple days i was elated.  it > seemed that i could have my margaritas and mexican food and get by > with no acid reflux.  i felt like a criminal getting by with the > crime.  well, within about 7-10 days i would feel like there was a big > lump in my diaphram and that i couldn’t belch to save my life.  it was > like there was no digestion going on whatsoever.  the feeling was > worse to me than the actual acid reflux and pain/pressure i had > experienced in the past.  once i would stop the new drug, that problem > would resolve within a couple of days and i would get back on the > protonix.  i am now diligently keeping a food diary and being very > good about my diet.  i am losing weight because i am eating smaller > portions.  i have also elevated my bed.  things are soooo much better > now.  i am just curious if you have heard of others having that > experience with those meds?  thanks again for sharing your time and > knowledge with all of us here….guess we are all a mess!

I have seen people respond and not respond to virtually all of the anti-secretory medications on the market. Some of those medications work great for some people and not for others. Some people who have had such meds work well for years stop responding. The reasons for this are variable and speculative. They appear to relate to changing function of the lower esophageal sphincter. As I said previously, anti-secretory medication doesn’t affect the LES, only the amount of acid available for reflux. And this can vary during the course of a day. Prilosec blood levels can change during the day and if you take it once in the morning as typically recommended, the blood levels may be low in the evening. Nexium is basically the same drug as Prilosec, but with different absorption and release so it supposedly maintains higher blood levels over a 24 hour period. I have seen this to be *generally* true, but certainly not *universally* for example. The key point is that medication and lifestyle changes are the way to go as long as they are controlling your symptoms to your satisfaction AND as long as their is no progression of damage to the lower esophagus (esophagitis, stricture, Barrett’s). If lifestyle changes and medications AREN’T controlling your symptoms to the point where you can live with it, or if there IS evidence on EGD of esophagitis, stricture, Barrett’s, then it’s time to consider surgery. Surgery for GERD is remarkably effective, but like all surgery should only be done if there is no other way to address the issue safely and effectively. I cannot emphasize enough that long term GERD patients need a screening EGD to evaluate for reflux damage because of the very well-defined relationship of esophageal cancer to reflux. Barrett’s esophagus is readily discernable on EGD. HMc

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> I would like to add to this Howard with your aproval. A healthy diet itself > can decrease chances of cancer with the right amount of antioxidents and > greens as well correct?

Doug, there is no question that a healthy diet is an important aspect of long term health, but there are huge variations within that "healthy diet" label. The theory of anti-oxidants and free-radical scavenging relative to cancer and heart disease is very interesting and is borne of some interesting lab work. However, it has never been shown in practice in randomized double-blind studies to be significant. One problem is the bioavaliability of the various anti-oxidants. These things are not closely monitored by the FDA as prescription drugs and there is a huge variability in quality, ranging from good bioavailability to outright scam. I believe that the key to many human ailments lays in free-radical scavenging, but we aren’t there yet. So far, there has been nothing in the anti-oxidant arena that has been shown to be effective, even though the science behind the theory is interesting, and may hold some promise. Just my opinion…. HMc

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