EVERYTHING YOU NEED TO KNOW ABOUT ACID REFLUX

03/29/2018

EVERYTHING YOU NEED TO KNOW ABOUT ACID REFLUX

Pharmacy shelves are full of medications for reflux or "heartburn." Most of us know the symptoms: a burning sensation in the chest with belching; sour stomach fluid coming up into the mouth; or a sudden awakening choking on burning acid in the airway. These symptoms are very common, affecting 40% of Americans monthly and 18% of Americans weekly.

In addition to annoying symptoms, untreated reflux could eventually cause death due to esophageal cancer.

Esophageal is one of the deadliest cancers and strikes about 14,000 Americans every year – and the numbers are growing rapidly. Research shows the increase in reflux and cancer is directly related to the nation’s increase in obesity. There is a correlation between increased weight and heartburn and between weight loss and the improvement of heartburn symptoms. In 1991, 15% of Americans were considered obese and 30% were considered overweight. Today 30% are obese with 60% overweight.

What is Heartburn or Reflux?

The stomach normally produces acid to aid in the digestive process. The problem is not the acid, instead the problems start when the acid comes up -- or refluxes -- into the esophagus.

We are able to breathe because the rib cage and diaphragm function like a bellows. The diaphragm is a sheet of muscle separating the chest cavity from the abdominal cavity. In the middle of this muscle is a hole, or hiatus allowing the esophagus to join with the stomach. When you inhale, the diaphragm contracts and expands the chest cavity, allowing air to flow into the lungs. As the rib cage expands, it decreases chest pressure and increases abdominal pressure. Reflux can happen because gases and fluids tend to flow from high-pressure areas like the abdomen, to low-pressure areas, or the chest. When you inhale, the pressure can pull acid up from the stomach into the esophagus, up into the mouth, airway or into the lungs.

The body is designed to keep all this from happening and acid reflux only happens when something goes wrong. Factors that allow reflux include:

TLESR (transient lower esophageal sphincter relaxation). The lower esophageal sphincter is a weak ring of muscle closing off the bottom of the esophagus from the top of the stomach, preventing acid from rising. But sometimes the sphincter relaxes when it shouldn’t.

Delayed acid clearance. When sleeping, we stop producing saliva, which helps clear acid from the esophagus. Saliva also contains growth factors that heal the esophagus from the damaging effects of acid.

Reduced resistance to injury. Once your esophagus or stomach are injured, if you have an existing ulcer-the injured tissue loses its protective defenses and is much more susceptible to further injury.

Delayed stomach emptying. Food and acid can sometimes sit in the stomach longer than usual.

Sleep apnea. The partial blockage of your airway can cause your chest to expand harder than normal. This pulls more acid into your esophagus.

Hiatal hernia. This condition occurs when a portion of your stomach protrudes into your chest cavity through the hiatus. It forces the lower esophageal sphincter open and basically brings the food and acid up into your chest.

In the long term, acid reflux can lead to ulceration or stricturing (narrowing) of the esophagus, which makes it difficult to swallow. It can also lead to Barrett's esophagus, a mutation in the lower esophageal tissue that can eventually develop into esophageal cancer.

Cigarette smoke and alcohol, especially in combination, can worsen esophageal injuries. The theory is the esophagus is protected from toxins in cigarette smoke by a mucus lining, as well as the swallowing of saliva, which washes acid out of the esophagus. Alcohol dissolves the mucus layer and also dissolves the smoke toxins so they are absorbed directly through the esophageal surface. If you have acid reflux, smoking and drinking can greatly increase your risk of complications, including the development of esophageal cancer.

How is Reflux Diagnosed?

Your doctor may suspect reflux based on your symptoms and will usually confirm the diagnosis with an upper endoscopy, especially if any “red-flag” symptoms are present.

These red flags may include:

Difficult or uncomfortable swallowing

Unexpected weight loss

Vomiting blood or material that looks like coffee grounds

Black, tarry stools

An onset of symptoms after age 50

A sudden disappearance of reflux symptoms without any change in lifestyle, body weight or medication may suggest the development of Barrett's esophagus-a mutation that will protect you against reflux but can lead to cancer of the esophagus.

Medication Options

The antacid aisle at the drug store can be confusing. There are dozens of options offering different results, and it’s important to have a basic understanding of how they work and what can be expected of each.

Acid neutralizers such as Tums, Rolaids, Alka-Seltzer, Maalox and milk of magnesia.

These medications work by neutralizing the acid already produced in the stomach and are largely available over the counter. They can be effective for occasional symptomatic reflux. If you have other medical conditions -- especially kidney disease -- use caution with over-the-counter preparations containing calcium magnesium or phosphate.  Since Alka-Seltzer contains aspirin, use the Alka-Seltzer Heartburn preparation for acid reflux because it doesn’t contain aspirin.

H2 blockers, or histamine blockers, such as Pepcid, Zantac, Tagamet and Axid. 

These medications work by blocking much of the acid produced in the stomach. They are available in both over-the-counter and prescription strength. H2 blockers are more effective for frequent heartburn treatment and for healing injury to the esophagus than the acid-neutralizing medications.

Proton pump inhibitors (PPIs), such as prescription-strength Prilosec, Nexium, Aciphex, Protonix, Zegerid,Prevacid and Kapidex. 

Theses medications block the final common pathway of acid production in the stomach and are the most effective for healing and maintenance of symptoms. Prilosec has an over-the-counter option but it’s not time-released and not as effective as the prescription strength. Most of these medications should NOT be taken with Plavix, an antiplatelet agent for the prevention of heart attack or stroke. PPIs may interfere with the effect of Plavix. If you take Plavix and are on a reflux medicine, check with your doctor or pharmacist to be sure it’s safe.

Non-Medication Treatments

If you want to avoid taking prescription medication for acid reflux-or if you’ve tried it and your reflux is still a problem-you might consider the following treatments:

*  Surgery can tighten the junction of the stomach and the esophagus. (Information on surgical options are outlined in Dr. Legrand Belnap’s article: “When Surgery is Needed to Correct

Acid Reflux”, also in this issue).

Lifestyle modification, primarily weight loss, can have dramatic results. But even if you don’t have a lot of weight to lose, eating smaller meals and going to sleep with an empty stomach can help.

Elevating the head of the bed a few inches with wooden blocks can make a difference. Let gravity help you.

You now should have a better understanding of what acid reflux, how it develops and the possible treatment and lifestyle options to help alleviate its uncomfortable symptoms. This information can help prevent potential complications resulting from untreated, long-term exposure of the esophagus to acid. If you have frequent symptoms -- especially a red-flag symptom – you should see a Gastroenterologist. And, if you have acid reflux, avoid the following:

Eating large volumes of food

Eating less than three hours before bedtime

Caffeine, including coffee and soft drinks

Liquor, including wine and beer

Citrus, tomato, and cranberry fruits and juices

Ice cream or milkshakes

Chocolate (one of the worst offenders)

Sour cream

High-fat desserts

Peppermint (one of the most potent esophageal sphincter relaxers of all! Avoid those after-dinner mints)

Overly tight clothing.

Eating out when you have acid reflux can be difficult.  Eating a large meal consisting of fried and fatty foods, accompanied by a glass of wine followed up with a chocolate dessert and cup of coffee. Of course you grab some mints on the way out and go to bed an hour or two later. You have just set yourself up for the China Syndrome of Acid Reflux.*

 

The following foods are safe to eat:

Mineral water (neutralizes the acid)

Most vegetables except fried potatoes and raw onion

Lean, non-fried meat

Apples

Bananas

Multi-grains

Low-fat dressings (vinegar and olive oil)

Low-fat desserts like sorbet

 

The following medications may also cause or worsen acid reflux

Nonsteroidal such as aspirin or Motrin

Calcium channel blockers

Anticholinergics

Beta agonists

Dopamine

Bisphosphonates such as alendronate for osteoporosis

Sedatives

Steroid such as progesterone

Antibiotics

Antihistamines

Reflux in Redux

Understanding the nature of digestion helps in understanding the nature of acid reflux. There is a tendency -- even among physicians -- to think of the digestive process as being magical. It is grand in its simplicity and sequencing. Whenever I try to simplify a subject for the public or my patients, I find myself struggling to find a balance between adequately explaining, overly explaining, overly simplifying etc. If this seems too simple, I apologize. If this is too complex, I apologize. if you try to bear with me I think you will understand.

How we derive nutrition from food

To illustrate this, we will use a piece of your favorite pizza. I chose pizza because it is representative of the food groups and most people like pizza.  The example is not overly relevant so you have permission to substitute a food that combines carbohydrates, proteins and fats.

Pizza contains what our bodies consider to be the 3 major food groups:

Carbohydrates, represented primarily by the bread, but also vegetables and some of the cheese components and most of the tomato sauce. Carbohydrates are basically long complex chains of sugars -- some are digestible in our bodies and some are not. Carbohydrates also contain the fibers listed and carbohydrate counts which are of no real significant nutritional value to us.  The value of fiber in the diet is to act as a scrub brush in the lower intestine to help clean the lining of the colon. It is this fibrous matter, in conjunction with dense cells from the intestinal lining making up the majority of our bowel movement volumes. The digestible carbohydrates are of relatively low potency for energy production with 1 g of carbohydrate yielding between 3 and 4 kcal of energy.

Proteins represented in some of the plant products such as vegetables and also in the cheese and in the meat – pepperoni, sausage or ham. Proteins are long complex chains of amino acids folded in tight packages and protected by connective tissue boundaries that must be broken down to get to the elemental proteins.  These must be broken down further to derive the amino acids used to power the cells of the body. 1 g of protein provides about 5 kcal of energy.

Fats represented in the cheese and in the meat and in any oil present. Fats or complexes of cholesterol and varying change legs of glycerides and fatty acids present in the food must be degraded and solubilize to be absorbed into the body. This calls for special function in handling fats which is bile, functioning as a detergent to emulsify fat or break it down into tiny fragments called micellar units.  These units can be absorbed into the lymphatic system of the intestinal tract and brought to the liver for processing further. 1 g of fat provides about 7 kcal of energy. (The highest kilocalorie per gram-year-old comes from alcohol at about 9 kcal per gram we really don't recommend  it as a basic food group.

So what is the first thing that happens with a piece of pizza?  Just looking at the picture above triggers your eyes, which are nothing more than highly developed and specialized skin connected through the nervous system to the base of the brain.  Then they are connected to the occipital lobe of the brain with subsequent connections to the cerebral cortex. This is important because the first phase of digestion is triggered by the eyes, the sense of smell, or just hearing about food. The thalamus in the base of the brain, in conjunction with the medulla oblongata in the brainstem, exert control over the vagus nerve along with a plexus of nerves called the myenteric plexus supplies the lining of the intestinal tract and plays a major role in the digestive process. This is the cephalic phase of digestion and triggers the initial production of acid in the stomach, contributing about 30% of total stomach acid volume and leads to salivation in the mouth and movement of the GI tract, particularly a growling crushing sensation in the stomach. This sometimes is audible and the noise is called borborygmi.

Now we have the pizza in hand.  We can feel it and we can smell it.  The smell is closely tied into taste, so by smelling the pizza we are actually getting molecules of the organic substance into our mouth triggering the production of saliva.  We take the first bite. Our mouth is now awash with saliva and we are chewing the food quickly.  The process of mixing saliva and chewing is very important for digestion. Saliva is a mixture of glycoprotein mucus in conjunction with two different enzyme called salivary amylase and salivary lipase.

The function of salivary amylase is to start breaking down carbohydrates into more manageable fragment size of sugars and starches.  This happens at physiologic pH and will likely be inhibited once the food reaches the acid of the stomach.  We can taste the weakness of the food because of dysfunction in the mouth.  Also, in the mouth we can taste salt in this sourness bitterness as well as the sense of the texture of fats because salivary lipase production initiates the first steps of fatty breakdown.

Once we have chewed adequately, it is time to swallow and this is probably one of the most underappreciated and dangerous tasks our bodies perform. The vagus nerve is part of what is called the autonomic nervous system.  Some people mispronounce it as automatic and they are not really wrong. It takes care of the things we take for granted, such as maintaining our blood pressure when we rise from a seated or lying position as well as allowing us to breathe and carry on our basic functions of daily living without having to think. We never really think about the danger of moving food and liquid from the mouth past the airway into the esophagus until something goes wrong with the process and we suddenly find ourselves choking. This is not the time to address problems with the swallowing mechanism. However, the swallowing process can best be explained when:

The sides of the tongue curl up the tip of the tongue flips backward tossing the bolus of food or liquid into the back of the oropharynx and top of the hypopharynx.

With perfect synchronization the oropharynx and palate and hypopharyngeal wall relax to receive the food bolus as the hyoid bone is lifted upward.  This closes the glottis across the airway, forming an air and watertight seal to prevent food or liquid from going down the trachea into the lungs.

Now there is a small swallow of saliva and basically rinse and repeat rinse and repeat rinse and repeat as mentioned above 60% of us are rinsing and repeating too much

(Illustration of the swallowing mechanism cross-section of the oropharynx etc.)

The Esophagus Itself

Now the food is in the cricopharyngeal, or upper portion of the esophagus.  The upper third of the esophagus contains a voluntary skeletal muscle.  About a third of the way down the esophagus there is a transition to an involuntary smooth muscle.  The basic function of the esophagus is to propel the food and saliva mixture into the stomach and then seal it off. This is accomplished through the motor function of the esophagus with stripping – peristaltic -- waves progressing downward from the mouth to the top of the stomach.  These are waves of contractile pressure forcing the food bolus down the esophagus.  If however, the esophagus did not relax in front of the contractile wave, there would be problems with the advancement of the food.  But in anticipation of the wave, the esophageal muscles relax the head of the contractile wave allowing easy passage. Even between meals, the esophagus clears itself with waves of contraction rinsing itself with swallowed of saliva which tends to wash out the acid that might reflux up from the stomach. The saliva also contains epidermal growth factors enhancing growth and repair of the esophageal tissue that might be damaged by acid reflux.

Now the Pizza Is in the Stomach Hallelujah!

 

(Illustration of the stomach with the gastroesophageal junction labeling the esophagus gastroesophageal junction the fundus corpus the antrum and the pylorus)

Our piece of pizza will spend quite a bit of time in the stomach in a dark, harsh chemical and mechanical environment.  What happens to the pizza?

For the first approximately 40 minutes, the body and the antrum are contracted, The food is stored in the upper dome of the stomach under the heart on the left side.  This area is known as the fundus, Latin for well or hole. During this time, acid is working on the food, breaking down connective tissue and cellular barriers and unfolding long chains of proteins, large globules of fat and long chains of carbohydrates.

Acid.  Not the villain we are made to believe.

 

Gastric acid -- also called HCl -- is produced by parietal cells in the lining of the stomach, found  predominantly in the body and the fundus. Production of acid requires an energy driven system within the cell called a proton pump. The proton pump actively moves sodium and potassium through the cell with resulting reflux of chloride and hydrogen protons into the stomach. These proton pumps are stimulated by these modulators:

Acetylcholine. The nerve transmitter important for movement of the stomach muscle in the grinding process. This movement triggers blood flow to the stomach and is one of the mediators of acid production in anticipation of in coming food.

Histamine 2.  This is the pathway blocked by Zantac, Tagamet and Pepcid.

Gastrin. A hormone produced by G cells in the stomach in response to perceived need for acid production.

All the of these pathways converge on the proton pump and will be blocked by proton pump inhibitors such as Prilosec, Nexium, Prevacid etc., blocking the final common pathway of acid production

The stomach lining also produces an enzyme called pepcinogen, produced by the chief cells of the stomach lining. This pre enzyme is converted in the presence of stomach HCl into pepcin, which is a potent digestive enzyme, but it doesn’t activate until the food enters the small intestine where the pH will increase, creating a less acidic environment.

After about 40 minutes in the fundus of the stomach, the body of the stomach relaxes to allow the fluid to enter the middle portion, where most of the folds of the stomach are located. There is increased acid production in this area. There is further production of stomach acid as well as further enzyme production.  In this area, the food will be ground mechanically into smaller and smaller pieces.

After about 40 minutes in the body of the stomach or corpus, the antrum relaxes and the food enters the lower portion of the stomach where further exposure to acid occurs and further grinding. At this point, there is a slight opening of the contracted pylorus of the opening muscle, controlling outflow from the stomach into the duodenum, or the first portion of the small intestine. As soon as the first acid and food bolus – chime  -- enters the duodenum, the pylorus spasm closed again. The presence of acid fat carbohydrate and protein within the first portion of the duodenum triggers release of three different hormones. These hormones are extremely important in further digestion of food, which has now been broken down slightly to allow chemical digestion to begin.

The Importance of Stomach Acid

Stomach acid occurs naturally and is responsible for some very important functions.  Among these are:

Help with uncoiling of larger chemicals or exposure to enzyme activity in the chemical digestive process, further downstream from the duodenum

The conversion of iron and calcium through a reduction reaction and into a form the body can absorb in the first portion of the duodenum. This is a pH-dependent phenomenon meaning, in the absence of acid calcium and iron it cannot BE rendered into the appropriate absorbable form, resulting eventually in problems with potential anemia or bone mineralization consistent with osteoporosis.

Stomach acid kills most bacteria, allowing for a sterile small intestine.  This means a small intestine not full of bacteria -- competing for nutrient absorption with our body producing harmful metabolites from its digestive process -- can lead to problems with bloating, gas and diarrhea in a condition known as bacterial overgrowth. This can also lead to increased susceptibility to more pathogenic bacteria such as Salmonella, vibrio, and Clostridium difficile.

Activation of digestive enzymes.

Conversion of pre-enzymes to their active form for further chemical digestion

(Illustration of the duodenum next to an illustration of an S. trap of a toilet or sink

The anatomy of the duodenum is controlled at the entry by the pylorus -- at the beginning of the duodenum and the end of the stomach.  At the end of the stomach is a ring -- a very powerful muscle capable of closing off effectively. From the pylorus, we enter into the bulb of the duodenum.  From there, we move around a very sharp turn to the second portion of the duodenum -- or duodenal sweep. About 8 inches down the duodenum, we run into a nipple -- or valve -- on the left wall of the duodenum which is the entry of the common bile duct and pancreas duct. The probable reason for placement of the valve at this position is the S. trap of the anatomy, of the duodenal sweep, will prevent the enzymes and chemicals coming from the pancreas, bile duct, and gallbladder, from easily back-flowing into the stomach. This would disrupt the food digestive process before reaching the duodenum.

Secretin. A hormone produced in the first part of the duodenum triggering release of pancreatic enzyme and bicarbonate into the lower portion around the S. trap of the duodenum. There is significant flow of bicarbonate and digestive enzymes, including trypsin and chymotrypsin, which are secreted in their active form and converted in the presence of each other and of acid coming from the stomach. These enzymes are necessary for the breakdown of proteins into basic amino acids, which can be absorbed in the microvilli -- in the surface of the small bowel -- completing the digestion of proteins. Simultaneously, secretin will cause the release of pancreatic amylase and pancreatic lipase. We have seen examples of these two enzymes coming from the mouth with the saliva, but these are much more significant amounts with the function of pancreatic amylase being the further breakdown of starches and complex sugars into more basic simple sugars that can be readily absorbed into the small intestine lining as well. Pancreatic lipase performs a similar function for certain types of fat, causing hydrolysis for breakdown to create a more absorbable form, with some of the simple fatty acids being able to be absorbed into the stomach lining directly, while more complex fats will require further interaction

Cholecystokinin, also known as CCK, the synthetic form used to test the function of the gallbladder in a CCK HIDA scan looking for abnormal gallbladder release, which usually tests for problems with the bile duct opening -- also known as the sphincter of odi. This hormone causes contraction of the gallbladder and bile duct and possibly the pancreas duct, as well as relaxation of the sphincter muscle, allowing the flow of bile into the third portion -- or lower duodenum portion. The purpose of bile in our digestion is to function as a detergent. The function of bile dyskinetic can break grease down into tiny fragments surrounding itself with a shallow of the detergent through a process known as micellar formation. This allows the micellar units to be ingested into the lining of the small intestine.  In the absence of bile grease would not be properly emulsified down to the smallest units and would pass through the large intestine in absorbed fashion, presenting a rich diet to the bacteria of the colon resulting in release of dietary bacterial byproducts resulting in diarrhea, abdominal pain and bloating etc. This happened during an attempt to use a nonabsorbable oil called Olestra in the preparation of potato chips several years ago. It resulted in people having diarrhea after eating the potato chips.

Gastric Inhibitory Peptide Also Known as GIP. This hormone is a member of the secretin family of enzymes and probably has a motor affect to decrease stomach emptying and stomach activity to slow down the process -- allowing chemical digestion to proceed at an unacceptable rate in the small bowel. This exertion of control is why it takes about 3 or 4 hours for most meals to empty the stomach. Certainly our pizza meal will behave in this way. Peptide is also involved in the stimulation of insulin production in response to food entering into the duodenum -- particularly proteins and carbohydrates. This production allows the blood stream to deal with nutrients being absorbed into the lining small intestine lining.

So What Does This Have To Do with Acid Reflux

We’ve talked in length about acid reflux, but we haven't talked about everything else that can reflux. All these enzymes and bile are capable of refluxing from the duodenum into the stomach and subsequently from the stomach into the esophagus. This type of reflux is not covered by treatment with antacid medication and there is some data to suggest some antacid medications for the proton pump inhibitors might actually facilitate reflux of bile and digestive enzymes. It is even speculated that bile may perform a significant role in the production of the precancerous transformation of the esophagus known as Barrett's esophagus change. It is important for the patient and clinician to consider the entire digestive process while thinking about esophageal reflux disease. Bile for instance, will not respond to antacid medications, but does respond to alginic acid, also known as Gaviscon liquid over-the-counter as directed and is certainly worth trying for patients who are not responding to acid suppression or who have taken acid suppression with good results and are now having breakthrough symptoms, possibly because enhancement of bile reflux from the acid stopping medication. There have even been studies showing possible abnormal function of the gallbladder and biliary system in association with the use of certain types of acid suppressing medications.

Overall, I would say the human body function is complex and full of surprises, especially for anyone who thinks they have mastered the physiology of humanity. We should always try making sense of clinical symptoms in light of physiology to consider the possible interference of medications and lifestyle in the disease pathway and to listen to the patient and let them explain the situation. If given the opportunity, most patients are able to communicate enough to suggest a reasonable diagnosis without extensive testing.  This way, testing can be used for confirmation.

Differentiating Acid Reflux from Bile Reflux

Acid is sour like lemon juice, but bile is bitter like green herbs. Most patients have some reflux of food into the mouth or awakening with reflux of liquid into the mouth.  If the liquid is green, yellow, or bitter tasting, or if there is a family history of gallbladder or epigastric problems, or right upper quadrant abdominal pain with radiation into the back, nocturnal awakening at night with delayed gastric emptying -- meaning that the patient doesn’t like food is sitting in the stomach all day long after eating -- suggests the possibility of bile reflux.

Acid response to proton pump inhibitor therapy. Failure to respond to reflux therapy with a medication like omeprazole doesn’t suggest the need to increase, or triple the treatment with omeprazole, but rather consider the possibility of bile reflux. Prolonged treatment with a proton pump inhibitor no longer responsive, should trigger consideration of another diagnosis

Food triggers acid production. When the stomach is empty, there is no acid, therefore if you are awakening in the middle of the night, or have not eaten for many hours after having acid reflux, it may be bile reflux.

How Does the Stomach Protect Itself

The stomach does not digest itself. The stomach produces a 7 µ layer about the thickness of the bacteria of mucus and bicarbonate. This completely protects the stomach lining from acid and enzymes. We get into problems with stomach ulcer development when something happens to prevent this barrier, or we eliminate this barrier by:

            1.  Aspirin and nonsteroidals are famous for producing stomach acid ulcers. They don’t actually affect stomach acid. The chemical nature of these drugs are a minor irritation to the stomach lining, but they do stop inflammation in the body by blocking a biochemical pathway called the cyclooxygenase-2 pathway.  Part of this is a prostaglandin cascade that produces inflammatory mediators in response to injury in the body or inflammation. Unfortunately there is a biochemical crossover in that one of the resulting product prostaglandins called PGI2 is responsible for the production of the mucus and bicarbonate slime that covers and protects the stomach lining. Taking aspirin or nonsteroidals can reduce the production of this mucus and bicarbonate layer, allowing the acid and digestive enzymes to come into contact with the stomach lining creating, ulcers or significant inflammation.

 Helicobacter pylori infection. This bacteria gets a lot of atteniton because of its role in ulcer development and its role in cancer development --  either lymphoma or adenocarcinoma of the stomach lining. The bacteria causes ulcers because it produces an enzyme called urease. It is capable of breaking down the mucus and bicarbonate protective slime allowing injury to occur. There is also an immune response component to this as well. It is very important to note about H. pylori and its treatment. First, eradication of the bacteria should be followed by biopsy to assess eradication rather than blood testing since it takes some time for the blood test to convert. The test is for an antibody to tell you the patient has had H. pylori infection, but doesn’t differentiate whether it is ongoing. The second important thing to remember is the presence of H. pylori bacteria in the stomach actually suppresses stomach acid production, therefore treatment or eradication of the bacteria will often result in worsening of acid reflux rather than improvement.

Bile Is a Detergent and it doesn’t belong in the stomach. The anatomy and physiology of the human body tries its best to prevent that from happening. As a detergent, bile can easily wash away the protective lining, allowing damage to occur.  It probably also washes away a similar protective mucous lining in the esophagus allowing injury to the cells. I have done many thousands of endoscopic examinations over the years. Every time I passed the scope into the stomach I tried to see what is in the stomach. When I first started scoping I saw more empty stomach or stomach acid in response to the scope -- as part of the sensation of incoming food, triggering acid production. Over the years I have seen a transition to significant number of patients with a stomach full of bile and have also noticed a change from years ago when there was significant pyloric muscle tone making it difficult to advance the endoscope into the pylorus from the stomach. These days I tend to see a wide-open pylorus showing no resistance whatsoever. I don’t know what is causing this change. I suspect that since most of the patients coming to us these days are already on acid reducing medication, certain classes of acid reducing medication may actually impair a normal motor tone of the pylorus and possibly of the intestinal system certainly of the bile duct function itself.

Where Do We Go from Here?

I really don't have the answer. I think we need a better understanding of the functions of the biochemistry and physiology of the human digestive system. During the limited research I did for this feature, I came across information questioning whether proton pumps might actually form an important function in the GI tract of earthworms as a neurotransmitter meaning that they are responsible for the movement of the GI tract. If that is the case in the earthworms it is possible in higher organisms as well and probably needs further investigation as a possible cause of some of the side effects that we see with proton pump inhibition. They are given out like candy -- even readily available over-the-counter.  We are not following current protocols in terms of who should be scoped before going on to these medications and their potential role in masking or serious symptoms of major illness with treatment without assessment.

But in medicine, research and studies change protocols daily.  As always, when in doubt, ask your doctor.

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