Wednesday, October 19, 2011

Dealing with Acid Reflux

I’ve seen numerous patients who have acid reflux, or what we in medicine call GERD, which stands for gastrointestinal reflux disease.  One patient stands out though and that was a 49 year old male patient who I saw in the GI clinic I was working in one morning. 
I knocked on the exam door and walked in to be greeted with the patient, whom I’ll call Dan and his wife. 
“So, what brings you into see us in the GI clinic, Dan?” I asked.
Angrily he stated, “the ER sent me.  I’m tired of this pain, but I’m really fed up with having to have waited three weeks for this visit!  No one wants to explain what’s wrong with me, all they want to do is give me meds and send me on my way.” 
“I see.  So where is your pain?” I asked.
Dan pointed to his upper portion of the abdomen over his midline. 
“Okay, how long has the pain been there?” I asked. 
“Months, maybe years,” Dan replied still angry. 
“What  medications have you taken for the pain?” I tried to ask calmly. 
“Too many.  The ER gave me some Nexium to try, prior to that I had been on Prilosec and Zantac.  But, the pain never goes away.  I want it gone!” Dan stated adamently. 
“Have any of the medications you’ve been on helped your pain?”
“The Nexium helped some, so I’ve been taking that.  The others didn’t do much of anything,” stated Dan. 

GERD, or gastrointestinal reflux disease is a very common disorder.  Many patients have it,  from those who are pregnant, to those who are obese, to those who have hiatal hernia (an outpouching of the bottom portion of the esophagus).  Typically patients take medications for it to suppress the acid formation in the stomach.  There are typically two forms of medications, one is called histamine blockers, such as Zantac, Tagamet, Pepcid, and the other one is a proton pump inhibitor, these go under the name of Prilosec, Nexium, Prevacid, etc. 

Thankfully as we continued to talk, Dan was beginning to calm down.  Maybe it was because he saw that I wasn’t dismissing him out of hand and sending him on his way. 
I took his medical history and social history and found out that he had two major risk factors for acid reflux and those were he was a 2 pack a day smoker and also drank a fair amount of alcohol every day. 
After doing his physical exam and only finding that he was tender over his upper midline of his abdomen, I asked him whether anyone had ever explained what acid reflux was all about. 
Much calmer now, Dan replied, ‘no.’
“Okay, well let me go get some pictures of what acid reflux is all about and come back in and go over them with you,” I stated.
I left the exam room, retrieved the GI teaching materials out of the conference room and returned to Dan. 
“Okay, Dan here’s some pictures for you to look at as I explain to you what’s going on inside of you.”
“No one has ever explained any of this to me, why are you doing it?” Dan asked.
“Well, because for you to understand what is going on with your acid reflux you need to understand where it came from and how to treat it.  You also need to understand why we are going to do an endoscopy on you, in other words we are going to put a scope down your swallowing tube, what we call your esophagus and take a look at it as well as your stomach.  So I need to explain all of this to you, so that you will comply with your medication regimen as well as show up for your scope procedure. “
“Okay, what’s this?” Dan asked as he pointed to the teaching picture of a patient’s esophagus and stomach.
“Okay,” as I pointed out the mouth, esophagus and then stomach in the pictorial, this is a picture of your mouth.  When you swallow your food goes into your esophagus and is then deposited into your stomach.  In your stomach you have acid which is meant to break down food products.  But sometimes acid is able to get into your esophagus, which as you see by this picture means it is going upstream.  When the acid gets into your esophagus you feel this as pain, typically right where you pointed with your finger at the beginning of this appointment.  Acid does not belong in your esophagus, because over time, it begins to break down the tissue that is there, and your esophagus’ response is to form a protective barrier of cells which are squamous cells (named squamous due to their cube shape).  And over time these cells can become dysfunctional and start to change into cancer cells.  So when you have your endoscopy we will be looking at this area right at the tail end of your esophagus and the beginning of your stomach.  If we see sometime suspicious we will biopsy it and let the pathologist tell us what it is.  If your endoscopy shows that you have Barrett’s esophagitis, which means that you have the changes which are reflective of the beginning of cancer cells, then we will be scheduling you for a regular follow-up scope procedures so that we can keep an eye on it and biopsy any further changes.  Barrett’s is the beginning of cancer, but it doesn’t mean that it has to change into cancer.”
“Do you follow all of that?” I asked.

There are many risk factors for Barrett’s esophagitis.  They include:
1)      Chronic longstanding GERD
2)      Age, mean age of diagnosis is 55
3)      Male sex
4)      Caucasian race
5)      Abdominal obesity.
Now of these risk factors there are only two which are amendable to change.  They include the patient’s weight, especially their weight around their waist line and whether they have GERD.  Risk factors for GERD include:
1)      Alcohol intake
2)      Smoking
3)      Abdominal obesity
4)      Pregnancy
5)      Fat intake 

“Yeah, but how does the acid get back up into my esophagus?” Dan asked.
“One of the ways it gets there is when you are sleeping, you sleep prone and therefore acid can easily get into your esophagus then, because it does not have to go against gravity.  Another way it can gain access is through eating fatty foods.  Fat has an affect on the gastro-esophageal sphinctor (GE junction, which is the separation between the stomach and esophagus, it is a small piece of tissue that blocks acid access back into the esophagus) .  Fat allows the GE junction to relax and therefore acid can take advantage of this and acquire entry to the esophagus.  Another way that acid can get into your esophagus is if you were obese, which you are not.  But if you were, the additional weight patients carry on their abdomen tends to pull the GE junction apart, which allows the acid access.  In addition you have two major risk factors for acid reflux and possible Barrett’s esophagitis due to your alcohol and smoking history.  Both of these work together to cause cellular changes in your lower esophagus.  And over time these changes can become cancerous.  So it’s for these reasons that we need to do what we call an endoscopy.   Okay?”
Dan nodded his head in agreement. 
“Now as far as your taking medications to prevent acid reflux that’s what the Nexium is for.  It prevents the acid from being formed by your proton pump cells which are in the lining of the stomach.  Seeing that you have told me that Nexium worked to some degree, what I’m going to do is increase your Nexium medication to twice a day dosing.  I want you to take the Nexium just prior to breakfast and dinner.  This way it will have time to get into your system, it will then be primed to turn off your proton pumps which are wanting to turn on when you present food into your stomach.  You can also take some Zantac on top of this at night if you have any symptoms.  You can take Zantac whenever, it won’t matter whether you take them with food or not.  If you have to take Zantac, you should notice a difference in your discomfort within 30 minutes.  Also I would like for you to stop off and see the clinic social worker.  Ask her for information on Alchoholics Anonymous and how to contact the local American Lung Association to quit smoking.  You need to do both of these, but try doing it one at a time.   Any questions?”
“No, I think you explained it all to me.  When am I going to be scoped?” asked Dan.
“I’ll send the nurse into schedule the procedure and she will give you the instructions on what you can have the day before the procedure and how long the procedure will take.  Here’s your new script for the  Nexium twice a day and here’s a script for the Zantac if you need it.  Here is your return to clinic appointment slip, make an appointment to come back in and see us within a few weeks of your endoscopy, okay?”  I asked.
“Okay,” Dan replied.
I walked out of the exam room, and looked at my watch.  I had ended up spending 1 ½ hours with him explaining everything and calming Dan down.  Hopefully it had been worth it, only time would tell. 

Medications which are used for GERD consist of two drug families.  The first drug family is called histamine blockers.  Most people are aware of  histamine blockers because they take one for their allergies, such as Claritin or Zyrtec.  These are classified as histamine type 1 blockers.  The histamine blockers we use for GERD are classified as histamine type 2 blockers.  These medications commonly go by the name of Tagament, Pepcid, or Zantac.  It doesn’t matter when you take these medications, they are able to get into the system and turn off the histamine releasing cells in the stomach which helps form acid.  Most patients who have acid reflux are able to take these drugs and they work just fine for them. 

Then there are those patients who have symptoms that are not totally controlled or controlled at all with a histamine type 2 blocker.  These patients need to be put on a proton pump inhibitor.  This class of drugs inhibits  the proton pump, which is located in the wall of the stomach.  The proton pump is responsible for forming the majority of the acid in the stomach, which is responsible for the initial breakdown of food products.

Proton pump inhibitor medications go by the name of Nexium, Prilosec, Prevacid, and others.  This class of drugs have to be taken either just prior to a meal or with your meal.  Taking them in this manner is the best way to make them the most effective.  They are then able to get into the system and are then primed to turn off the proton pumps which are trying to turn on when food is presented to the stomach.  These medications will not turn off the proton pumps if they are not trying to turn on. 
A couple of weeks later Dan was back on the GI clinic schedule to be seen.  I checked his endoscopy results and found that he had been diagnosed with Barrett’s esophagitis and would need a repeat endoscopy in 6 months.  I went in to see him.
“Hi, Dan how it’s going?”
“I’m better, my acid reflux is much better, I rarely have to take the Zantac, my Nexium is working like it should.”
“Glad to hear it.  Did they explain to you after your procedure that you do indeed have Barrett’s esophagitis?”
“I vaguely remember the GI physician telling me he thought I had it based on what he saw when he scoped me.” 
“Well, your pathology of all of the biopsies done shows that you do have it, you have what is called dysplastic cells, which could change over into cancer.  So we are going to have to put you on a regular schedule to scope you every 6 months for the foreseeable future. “
“Why do you do that?” Dan asked.
“We want to hopefully be able to prevent you from having cancer of your esophagus.  So with your staying on your medications for your acid reflux and your not having any more symptoms, hopefully you won’t transform into frank cancer.  But if you do, we’ll be on top of it and get you seen by a surgeon who can remove that portion of your swallowing tube.  Understood?”
“Yeah, I think so.”
“Now, what about your smoking and your alcohol intake.  Have you been able to make any progress with either one of those as far as quitting?”
“Pam, the social worker gave me info on Alcoholics Anonymous.  I’ve started to attend the weekly meetings in my area.  But it’s hard.  I don’t know whether I’m going to be able to do it.”
“Well, keep trying, it’s important for your health.”

Six months and one year later Dan had his repeat endoscopies.  His one year report showed that his Barrett’s esophagitis was regressing somewhat and beginning to return back towards normal cells again.  That was encouraging.  I saw him in clinic after that and he was happy with his response, his twice daily Nexium was still working and he had been alcohol free for 10 months with the help of Alcoholics Anonymous.  I could only hope that he would continue to improve. 

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