Dr. Kurt Barrett's GERD Blog

A "new" study was recently released and made the CBS NEWS and others. What I've seen so far is not new information. Some is actually "junk science"...i.e., clostridium difficle is an acid resistant spore and hence the pH of the gut should NOT BE RELEVANT since it is not altered by the presence or absence of acid. We can talk about the bias in the retrospective studies because it seems that some of these findings result from the disease state (GERD) not the from the treatment. The only people that take these drugs in these cases are PEOPLE WITH GERD. We have no information on what results would be if non-GERD patients took the same treatment.
That said, ALL meds have some risk. We need to do every thing we can to minimize that risk. The benefit /risk determination needs to be ascertained on a case by case basis. Concern for children should be acknowledged but given the lack of adverse results in the short run (months up to 5 years) I believe the risk (small) is clearly justified given the benefit. Similarily, I would not withhold penicillin in the child with fever and sore throat based on the possibility that anaphylactic reaction could result. The small risk seems acceptable since benefit in both cases is substantial.
I might add that I have treated hundreds of patients with P.P.I.s (Proton Pump Inhihitors) for over 25 years and I remain very impressed with their remarkable benefits and safety.

Gastroesophageal reflux disease (GERD) is becoming MORE common in our society. And this statement is made despite the fact that I meet people of all ages that have GERD related symptoms and have NO SENSE that gastric reflux is at the root of their problems. Their doctors don't either because the prevailing wisdom is you must have heartburn or indigestion to even consider GERD.
"Why didn't my doctor tell me about this?". My answer is that most of us patients and physicians, are overwhelmed by the "information glut". The concept that GERD causes more than heartburn is a newer concept and "hides" in this information onslaught. As a primary care, general practioner, and due to a family members illness, I have been enlightened as to the suprisingly frequent occurence of GERD. I try to look at the bigger picture of what ails my patient. I see specialists, due to, perhaps(?) the dogma of their classic training, that fail to "connect-the-dots". The pulmonologists, who treats the lung, fails to realize that there is OFTEN (over half the time!) a prominent association with GERD. I see infants who sneeze, cough, scream in pain and can't sleep at night under go a transformation...sometimes immediately...when GERD is recognized and treated. The dad of a 7 month old, who had the peditrician refuse to accept GERD as a cause of symptoms state, "He is like a different kid" immediately upon initiation of therapy for GERD. Same situation with a 4 month old. An adolescent who has been in the habit of having such severe coughing spells (presumed to be due to her asthma) that she ends up vomiting. In reality her asthma is precipited from acid reflux and so is her vomiting. I find people that could not finish a meal without coughing and now with appropriate GERD therapy only cough with illness. Perhaps if you realize that some people have a "runny nose" when they eat you can expand that understanding to see that eating can cause cough. BOTH conditions are caused by digestive contents arising from the stomach and intestine, flowing in reverse into the esophagus. These harsh digestive contents come in contact with an irritated lining of the esophagus caused from previous similar events BUT OFTEN THERE IS NO HEARTBURN. Even without heartburn, the body and the brain rightly recognize these events as dangerous. The response appears as sneezing, runny nose, mucus production, coughing and in some cases vomiting. The individual may (or may not) have difficulty swallowing. The esophagus correctly recognizes this reflux of digestive contents as "toxic" or harmful and thus responds in the only way it can devise to protect the person. The stimulation of the acid/digestive contents contacting the gentle, fragile lining of the food tube evokes the clinical responses. The physiological response induces mucus making tissues to pour out mucus type secretions to line, dilute and thus protect the esophagus. The severity of the danger in the esophagus results in " all out" stimulation of mucus producing tissues. Thus mucus producing tissues else where in the body "hear" the message to make mucus/secrete. Thus tissues remote to the actual insult become actively involved as if they were protecting themselves!

The numbers of sleep associated issues related to GERD are impressive BUT in my experience they are routinely ignored or overlooked. GERD patients can present (with or WITHOUT heartburn) complaining of: drowiness, daytime fatigue, frequent nocturnal awakenings, awakening non-refreshed, snoring, and/or experiencing unpleasant feelings of legs (or arms).
I speak to the Michigan Sleep Alliance (in Kalamazoo, Michigan) on March 18, 2010. The title of the presentation is, "Insomnia-What Role Might GERD Play?"
The National Health and Wellness Survey, with 66,000 participants, found 18% of this group were diagnosed with GERD.
The participants diagnosed with GERD reported:
-they required "more medical care"
-decreased Quality-Of-Life scores
-lowered work productivity
-reduced sense of well being
-87% had "sleep issues"!.....
-48% revealed trouble staying asleep.....
-56% claimed difficulty initiating sleep....

I find that physicians and providers only treat GERD when associated with heartburn. Their goal of therapy is, generally, to reduce heartburn. Beyond heartburn and indigestion little is recognized or acknowledged by primary and even gastroenterology specalists.
THE EYES ONLY SEE WHAT THE MIND ALREADY KNOWS.

I have, in my clinical practice, found an association with cardiac arrythmia and GERD. One source previously found 78% of patients in atrial fibrillation WHO HAD NO REASON TO BE IN ATRIAL FIBRILLATION responded favorably to treatment for GERD. There is now further documentation between GERD and atrial fibrillation. According to an article recently published in Clinical Cardiology, a Ventrans Administration study of 163,600 + adult patients revealed 5% had atrial fibrillation and 29% had GERD. Univariate analysis revealed GERD increased the likelihood of atrial fibrillation by "nearly 39%". My suspicion is that they probably would have found an even stronger association had they liberalized their criteria for diagnosing GERD. My kudos to Dr. Jeffery Kunz for shedding some insight into the arena of acknowledged consequences of reflux of digestive/gastric contents.

Jeffrey S. Kunz. Clin Cardiol 2009;32:584-587.

_A ten year old boy with "photosensitivity" for several years; several doctors(?) suggested treatment with Benadryl and sunblock which failed to give relief. His "condition" was in reality dermatographia thus no sensitizing medications were involved as a causative agent. Twice daily treatment with antisecretory treatment (Prilosec OTC) eradicated his longstanding skin problems in less than a week. His "sinus allergies" also got much better.
-A lady in her mid sixties undergoing chemotherapy for gynecologic cancer developed severe shortness of breathe causing hospitilization. She was discharged after a week in the hospital, in another community, with little improvement in her condition. Shortly after discharge from the hospital my history and exam suggested her GERD had relapsed. This went unrecognized as a reason for her symptoms. The amount and/or harshness of the gastric reflux into the esophagus was causing her lungs to protect themselves. The vagus nerve fibers, by reflex, were stimulated thus making mucus, favoring bronchospasm and causing neurogenic inflammation. At this visit her chart revealed an insurance mandated medication change. Her favored Prevacid was switched to omeprazole. Less than 4 months after this medication alteration her breathing deteriorated to the point of hospitilization. I was suspicious of GERD "relapse" even though her condition did not worsen in the first few weeks of the new treatment with omeprazole. Based on her exam and history I put her back on Prevacid and her difficulty breathing (dyspnea) resolved on day three (72 hours). I knew she was better when she worked in her flower garden for the 1st time in four months.

October 22, 2003
Dr. Kurt Barrett
1695 M-66
Athens, MI 49011

Dear Dr. Barrett,

Since I have not had to come in and see you lately, I wanted to write this letter to express to you my heartfelt thanks for improving my quality of life!

For a decade, I had been to several allergy specialists and underwent testing only to be told that they did not know why I had hives on a daily basis and categorized me as having dermatographia (a highly sensitive skin type). This was a very uncomfortable “condition” because in addition to hives all over my body, my feet hands and lips would swell, I had excess mucous in my throat (I constantly had to clear it before I could speak), and I developed a highly nervous disposition which I believe was what they now call social anxiety. Throughout my life, I was calm under pressure, always performed well with and in front of any sized group, and had many friends. I know the difference between what I was and what I had turned in to. These specialists tried many medications, notably: Benedryl, Seldane, Allegra and Clariton, which I took on a daily basis, to control my hives. In addition, they categorized my nervousness as the cause (not an effect) of my condition. Upon my request, the doctors switched my medication to Zyrtec which made my sleepy and a little less nervous. For the past ten years, that is as good as it got.

When you suggested that I try the Proton Pump Inhibitors (PPI’s), I immediately saw a reduction in nervousness and I no longer had to take Zyrtec on a daily basis to control my hives. The more I increased my PPI’s, the less Zyrtec I had to take (one pill every four days). My stomach acid was no longer as potent when it entered my esophagus.

When I tried the Baclofen to make the stomach/esophagus valve close, it decreased my need for Zyrtec to one pill every eight days!

Due to the fact that Bacolfen also made me sleepy, I decided to have the Nisson Fundoplication performed. This surgery, which wrapped the upper part of my stomach around the lower part of my esophagus, effectively keeps the valve closed.

I am ecstatic to say that I no longer have hives at all, no longer need to clear my throat in order to speak and my frame of mind is clear again. I feel more like myself. You have my gratitude and respect for the tenacity you showed in trying to fix my problem. Unlike other doctors who apathetically told me there was no cure, you were proactive in finding that cure. I am living proof that PPI’s work to reduce stomach acid in the esophagus, that Baclofen is a very effective gerd medication and that with the reduction of acid absorption by the esophagus through Nisson Fundoplication, a cure for a variety of illnesses is available.
I am happy to say I am free of medication, my hives no longer plague my daily existence, my throat mucous is gone and my social anxiety has completely abated.

God bless you for your efforts, and may he guide you in enlightening the medical community and the lives of others like me.

Sincerely,

Amanda

This lady was in her early 30's at the time this letter was written. In addition to her description of events she had a cholecystectomy (gallbladder removal). I have seen several patients who had experienced idiopathic urticaria resolve their chronic problem(s) in a similar manner, i.e. with sucessful, aggressive therapy for GERD.

-lose weight if indicated
-eat smaller portions, smaller meals more slowly
-raise the head of the bed 2"-8" if it seems to help...some controversy whether EVERYONE with GERD will benefit
-sleep/lay on the left side of your body when possible
-avoid/limit caffiene in coffee, teas, colas, chocolate, energy drinks....READ LABELS! (caffiene causes unwanted relaxation of the pinch valve in the lower esophagus which is named the lower esophageal sphincter or LES)
-avoid nicotine, same situation, it lowers LES pressure, a bad thing in GERD
-avoid mints (spearmint, peppermint, etc.) since they too cause relaxation of the pinch valve of the lower esophagus (wintergreen is okay)
-reduce consumption of fatty foods; they delay gastric emptying thus exposing the esophagus to gastric regurgitation for a longer period of time
-do not lay down after meals for 2-4 hours
-use "barrier antacids"...(the important ingredient is alginic acid or alginate, which allows for the "floating on top of the stomach juices" effect) after meals and at bedtime and and for symptom control: they are Gaviscon or Gaviscon like…store brand is fine
-the mainstay of therapy is medication to reduce (not eliminate) production of acid by the lining of the stomach: omeprazole, PRILOSEC OTC, Nexium, Prevacid, Aciphex, pantoprazole, Protonix, Zegerid, Kapidex are all forms of proton pump inhibitors….another group of less potent, usually less effective, OLDER, LESS COSTLY drugs are: Tagamet HB, Zantac, ranitidine, Pepcid, famatodine, Axid….all are forms of histamine 2 receptor antagonists

My daughter struggled with minor respiratory issues for 10 years. Home from college, in cold air she choked and turned blue. “I’m okay; I just have to get out of the cold.” I intuitively suspected something “wrong” with her esophagus. But without heartburn there were no answers ANYWHERE. Years later, in 2000, she called, “For the last two days I’ve had heartburn.” I suddenly realized she had something I had vaguely heard of; atypical gastro esophageal reflux disease (GERD). The hallmark of “ordinary GERD” is heartburn; in atypical GERD, its absence makes a digestive problem seem an unlikely cause. Since 2000 I have studied the body’s response to regurgitated digestive contents. I find respiratory diseases commonly associated with GERD. Each day I learn more, or better understand, this complex, common disorder some call “the great masquerader”. The University of Virginia School of Medicine states:”Symptoms related to GERD represent one of the most common, often confusing, health problems seen in primary care. The frequency of GERD has increased in recent years…” GERD is the only known cause of esophageal adenocarcinoma, the MOST RAPIDLY ADVANCING OCCURRENCE OF ANY CANCER IN THE UNITED STATES.
The Institute of Medicine (IOM) reports that it takes, “about 17 years for a new treatment for a given disease to make its way into routine patient care”. I this guess means we’re about half way there from a time line. Please remember, as some obscure philosopher once said, “The eyes only see what the mind already knows”.

I have recently encountered a rash of youngsters whom have been treated repeatedly, 5-7 times in the FIRST YEAR of life for recurrent (persistent??) "ear infections". YES they need antibiotics for the fever and presumed bacterial infection BUT why do they not get beyond this?
Consider the following November 2008 information:

Gastric pepsin in middle ear fluid of children with otitis media: clinical implications.
He Z, O'Reilly RC, Mehta D.
Division of Pediatric Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.

"Gastroesophageal reflux and extraesophageal reflux have been postulated to be involved in the pathogenesis of otitis media. This is supported by recent studies revealing the presence of gastric pepsin in the middle ear space of children with otitis media but not in control patients without otitis media. Reflux's role in otitis media appears to be most pronounced in younger children and those with purulent effusions."

My take is that over 80% of the children with these ongoing ear problems likely have GERD, the unwanted reflux of gastric contents. GERD results in gastric contents arriving in the middle ear creating an environment favorable for bacterial colonization and growth with resultant infections. When the cause is GERD sucessful treatment for GERD should result in dramatic reduction in the manifestations of ill health. Often sleep and mood improve concurrent with the absence of ear pain (otalgia, ear ache, is COMMONLY caused by gastric reflux).
It is beyond the scope of the study reported but realize that chronic ear infections may be the only recognized complaint or only one of many problems that result in both chronic and acute illness. Asthma, recurring sore throat, "sinus problems", hoarseness/voice problems,clearing of the throat, runny nose and cough are all OFTEN caused by GERD.

I'm terribly disappointed in the conclusion drawn from this study. A recent article in NEJM, authored by physicians at Johns Hopkins, determined that Nexium 40 mg dosed twice a day for twenty-four months DOES NOT help in asthmatics if they lacked classic GERD symptoms. The study has been praised by many scientists based on its design, etc. I trust their findings but I DO NOT endorse their conclusion. I believe the findings of limited benefit since the only valid conclusion I can make is no improvement in asthmatics AT THIS DOSE. I believe they could individualize a dose and treatment regime constructed to achieve improved outcomes in many patients with pulmonary problems by attempting to dose to the end point of eradication of symptoms. I have SEEN asthmatics and cough patients resolve by titrating (adjusting) the dose over a wide range to control the disorder. I have seen this in numerous cases. I believe the design of the study is flawed by the fixed dose as an arbitrary endpoint. It seems the study was designed from the opinion that "a single fixed dose fits all". The FAILURE to adjust the patients dose to achieve sign and symptom remission virtually ensures poor outcomes in numerous cases. For example some diabetics may require only 5 units of supplemental insulin for sugar control while another might require 50, 90 or even 100 units. Dosages of many medications must be individualized to achieve favorable outcomes. If you only gave each dabetic the lowest dose of insulin , tracking the outcomes would "prove" that insulin AT THIS DOSEAGE failed to control the majority of diabetes mellitus My experience is consistent with others who have found success by adjusting (titrating) the dose of anti-secretory therapy in EACH PATIENT, INDIVIDUALLY based on their personal response. Casteel reported in 1999 that the oral bioavailability of omeprazole varied patient to patient by a factor of "at least six fold". My experience indicates that GERD therapy needs to be based on individual outcomes on a case to case person by person basis. I've seen patients who needed double or triple the "ordinary" dose to safely achieve disease and symptom control. (Omeprazole has been used in Zollinger-Ellison Syndrome at 9-18 times the ordinary dose with no FDA limitations for at least 5 years consecutively).

The adage “all that wheezes is not asthma”, was first recognized by Chevallier Jackson about 100 years ago. It still rings true today. But is this a time-line of futility? Note the following facts:
In 1907 Sir William Osler reported on night time asthma…“attacks may be due to direct irritation of bronchial mucosa or…indirectly, too, by reflex influences from the stomach”.
In 1934, Bray proposed reflex mediated bronchoconstriction through the vagus nerve as a cause of wheezing.
In 1962, “Silent Gastroesophageal Reflux: An Important but little Known Cause of Pulmonary Complications” by J.H. Kennedy, Diseases of the Chest was published.
The book, “Gastroesophageal Reflux Disease and Airway Disease” edited by Dr. Mark R. Stein, in 1999, is a wonderful insight into this unapparent issue of asthma and a host of other pulmonary pathologies, originating from the upper gastrointestinal tract.
I authored “Are You Sick of Being Sick?” in 2002 largely dealing with similar issues.
Some call the pulmonary problems associated with gastroesophageal reflux disease (GERD) “gastric asthma”. Yet you NEVER hear a TV commercial for acid blockers to treat asthma. This is because manufacturers have not sought Food and Drug Administration (FDA) approval. They know that physicians routinely use medications “off label”, i.e. not approved by the FDA. Providers commonly find benefits in conditions beyond those acknowledged when approval was obtained from the FDA. The conventional wisdom for asthma therapy is using steroids, airway stimulants, mucus thinners, antihistamines and anti-inflammatory medications usually via inhalers. Yet GERD is associated with asthma in 82% of cases according to University of Virginia School of Medicine, 2003. Further more, they confirmed that, “larger doses” of acid reducers (than those used for heartburn) for a “longer period of time”, are necessary to relieve respiratory problems. They also point out that “most physicians” are not aware of these concepts. Where is the National Institute of Health?

Gastroesophageal Reflux Disease and Airway Disease” edited by Dr. Mark R. Stein is a wonderful summary of the intimate relationship shared by these increasingly common 21st century disorders. This book was published under the direction of the National Institute of Health, Bethesda, Maryland. They claim, “Gastroesophageal Reflux Disease (GERD) is arguably the most common disease seen in clinical practice and may present with a multitude of symptoms. An ever increasing body of evidence supports the importance of GERD as a significant factor in both upper- and lower-airway disease. Until now, this information had not been presented in a coordinated volume….This book is designed to fill that void, which is also present in most textbooks on asthma and respiratory diseases.” This volume discusses the common embryologic origin, otolaryngologic, oral (dental) and the intense relationship with GERD and asthma. I am particularly impressed by the body of knowledge presented regarding asthma, neurogenic inflammation and GERD. They discuss nerves that react to acid in the esophagus by directly inducing swelling, mucus production and vasodilatation at the origin of the acid in the esophagus and simultaneously in the trachea. In addition to these direct influences on the airway the contribution of the vagus nerve is examined. “Inflammation is a necessary defense mechanism that serves to protect the body from noxious insults. The precision of the host response to such insults is critical; compromised or insufficient responses can have dire, acute consequences, while exaggerated or prolonged inflammatory responses can precipitate chronic disease. Such exaggerated inflammatory responses might precipitate chronic inflammatory diseases such as rheumatoid arthritis, inflammatory bowel disease, GERD, and asthma”. Chapter 9 points out, in infant cases of severe GERD, “Left untreated, repetitive aspiration can lead to progressive pulmonary dysfunction and ultimately bronchiectasis , pulmonary fibrosis, and death

This middle aged man was under the care of the department of gastroenterology at a major university here in Michigan for over four years when we met last year. I spoke to the local sleep apnea support group in Battle Creek, Michigan; he was in attendance because he was intolerant of his C-PAP. He now controls his GERD with a single daily dose of medication, wears his nasal C-PAP all night, every night and no longer develops nausea at the smell of fatty foods cooking as he had for years. He moved away two weeks after the removal of his gall bladder thus I wanted to know how things worked out. His situation indicates how crucial attention to detail is when confronted with multiple symptoms involving multiple systems.

Dr Barrett:

Thank you for your calls to check up on my progress. It seems unbelievable to think that my asthma symptoms have disappeared since removing the gall bladder. My new pulmonologist here in Ohio cannot accept that in my recent past I have had a full asthma diagnosis. Furthermore, I have not experienced the larynx spasms or laryngitis. This is the first winter in at least ten years that I have not had multiple bouts of pneumonia and bronchitis.

My first introduction to the concept of possible connection between my chronic sleep apnea, sleep deprivation, asthma, and esophageal reflux came to me through the sleep center physician and staff in Battle Creek, MI. After consultations with Dr Barrett, extensive reading and serious consideration of his recommendations, I accepted his proposed therapies. After several months of increasing and decreasing pharmaceuticals and laboratory testing, it was determined that my gall bladder was diseased and my team of medical professionals fully agreed that a cholecystectomy was necessary. Within a few months the asthmatic symptoms have dramatically diminished and my pulmonologist ordered that I totally discontinue the use of Symbacort.

Prior to the above discoveries I restricted my attendance in most all public gathering places and especially encountering fragrances, humid environments, any firesides, and airborne particles. In addition to sleep disorders and respiratory dysfunctions, to mention a few, I have cardio-vascular disease, celiac spru disease, degenerative bone disease, and minneres disease. It seemed very remote that I might find relief for my newest of diagnosis, asthma but I am delighted with my results to date. Furthermore, it has been a pleasure to work with Dr Barrett and his staff.



Sincerely,

Richard G.

An interesting July 25, 2008 article from Webb MD helps explain the asthma and GERD connection:

Chronic heartburn may alter the immune system and raise the risk of asthma, according to a new study that helps explain why so many people with asthma also suffer from gastroesophageal reflux disease (GERD).

"Researchers say the link between asthma and GERD has been a mystery for years. Previous studies have shown that 50%-90% of people with asthma also suffer from gastric reflux, but until now the relationship between the two conditions was unclear.

The study shows that inhaling small amounts of stomach acid back up into the esophagus and lungs, a hallmark of GERD, slowly produces changes in the immune system that may lead to the development of asthma.”

An article released in CHEST. (2008; 134(6) 1123-1130.) from the United Kingdom documented from the study of 3 million patient charts that patients with a diagnosis of chronic obstructive pulmonary disease (COPD) are at a significantly increased risk of GERD. COPD is commonly known as emphysema. They also observed respiratory symptoms improve in patients receiving acid-suppressive therapy for GERD. Since the symptoms and diagnosis of asthma and emphysema commonly overlap it is prudent (but relatively uncommon) to consider GERD as a connecting theme. GERD is often associated with heartburn/indigestion but it is entirely possible to have GERD associated with asthma, emphysema and allergies and have little or no heartburn. This type GERD is thus called “atypical” or “silent”.

I have documented eighteen cases of patients who no longer demonstrate intestinal metaplasia on repeat or surviellience endoscopy of the esophagus. Several of these individuals have had more than one biopsy negative surviellence endoscopy . Sixteen of these case biopsy specimans have been confirmed at the University of Michigan. Two situations had no biopsy speciman obtained since the esophagus was determined to be normal at endoscopy. All cases are considered short segment. I have published fifteen of the cases in the American Journal of Gastroenterology*. The intensity of therapy was quite variable in regard to the dose of antisecretory therapy utilized. It is apparent the response of the person to the therapy for GERD needs to be carefully monitored with the intent of adjusting or titrating the intensity of therapy to achieve a desired response. It is perfectly clear that the doseage of antisecretory therapy varies rather dramatically among individuals. I site Dr. Donald Castell in my published cases. He documented greater than six fold patient to patient bioavailability of omeprazole in clinical studies.
Numerous surveys document the inadequate resolution of symptoms in the majority of GERD
patients DESPITE BEING ON PRESCRIPTION MEDICATIONS! This demonstrates poor understanding and imperfect management of this illness.





*Vol. 101, No. S2, 2006 Page 3, #6