Complications (GERD)

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.

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”.

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

In 1950 Dr. Norman Barrett, in England, was using a new technique to look inside the body. Through an illuminated, rigid, metal tube in the mouth he
looked down the throat into the esophagus. The lining of the food tube was a pale, pink similar to the inside of the mouth. In some individuals he observed the lining of the stomach located in the lower esophagus. The lining of the stomach is quite distinctive being a lush, reddish, appearance. He thus described a "tubular stomach". Utilizing this new technology, Dr. Barrett was the first to describe these findings. Thus it became known as Barrett's esophagus. The siginfigance of his findings (glandular tissue lining the lower esophagus) were unknown and as often is the case initially misunderstood.
We now know the lining of the esophagus undergoes this "change" as a result of reflux of stomach/digestive contents. The process of tissue changing from one type to another type is called metaplasia. Metaplasia is never a good thing. The pale delicate lining of the lower esophagus (the normal lining is called squamous epithelium) under goes metaplastic transformation to the lush, reddish, glandular tissue normally found only in the lining of the stomach. This type of tissue is called columnar epithelium. It is as if the body were trying to form a "callous" to protect itself from the harsh digestive juices and corrosive stomach acid. This type of lining in the esophagus is characteristic in appearance and is technically called a columnar lined esophagus. At the time of endoscopy biopsies are taken of this abnormal appearing tissue.
As time goes by continued reflux (years) may allow this glandular lining to undergo even further abnormal change when viewed under the microscope. If the biopsy speciman reveals the presence of Goblet cells (they have the ability to produce mucus) we now have, what in modern terminology, is called Barrett' esophagus. This tissue type is reffered to as specialized intestinal metaplasia. This is the first step in the direction of potenitally developing cancer of the esophagus. The next step in continued progression is called dysplasia. Dysplasia can lead to cancer and is thus a very troublesome finding.
To put this in its proper prospective you must realize that in the worst case situation only 1/2% of patients with Barrett's esophagus will develope cancer per year.

Former Texas governor Ann Richards recently died of esophageal cancer (she had squamous cell type).
Esophageal adenocarcinoma (EA) is:
-The most RAPIDLY growing incidence of ANY CANCER in the country.
-Occurrence of this cancer is DOUBLING every 5 years.
-This cancer is STRONGLY ASSOCIATED with GERD.
-The incidence of GERD has INCREASED in recent years.
-Esophageal adenocarcinoma is PRECEEDED by a change of the cell layer lining the inside surface (transformation of the epithelium) of the esophagus.
-This transformation of the esophagus "lining" (from squamous to columnar/glandular) is referred to as BARRETT'S ESOPHAGUS.
-Many people with Barrett's Esophagus will have OBSTRUCTIVE SLEEP APNEA.
-EA is NOT directly associated with alcohol and cigarette use as is squamous cell cancer.
-Long standing HEARTBURN at night, in a white male over 50, is a signifigant risk for EA.
-Possible in persons who have NEVER experienced heartburn.
-MUST be detected in early stage to effect a surgical cure in the 15-20% who survive.

A rare commodity in todays society, common sense. It must be differentiated from conventional wisdom. Reggie White, the great Green Bay Packer defensive lineman, died at age 43 after being suddendly stricken.
It is generally believed that he was a victim of Obstructive Sleep Apnea Syndrome. I just read in the sleep literature of a doctor who sent Reggie a letter 10 years ago warning of the dangers of sleep apnea and GERD. The letter went unanswered.
Conventional wisdom would say,"Why didn't my doctor mention this? It must not be too important".
Common sense answer would be,"Your doctor didn't know enough about this to 'connect the dots' and arrive at a life saving diagnosis."
The point is SOMEONE suspicioned the very problems that killed Reggie YEARS before the event. I promise you that he had "the very best medical care money can buy". The professional teams usually pride themselves on this idea that they MUST protect their investment. Conventional wisdom?

Millions of Americans are suffering from medically unexplained symptoms. Michigan State University recently published a "revolutionary treatment plan" for those with the diagnosis of "medically unexplained symptoms". They mention,..."The most common symptoms are back pain, headache, fatigue as well as musculosketetal, nervous system and gastrointestinal complaints".
I see this situation when the provider does not "recognize" your symptoms and when your testing turns out "normal" you are often considered functional or psychosomatic or the new term medically unexplained symptoms. Stedman's Medical Dictionary defines functional as:"Not organic in origin; denoting a disorder with no known or detectable organic basis to explain the symptoms".
If you persist or your story is convincing, testing will be performed. Often the intent is to demonstrate: 1) no cancer 2) no abnormal results. Now you could become labeled even more "difficult"; you're so "functional" that you continue to have symptoms even after you are told emphatically that all tests are normal! When told to quit complaining, take 8 Peto-Bismol tablets a day to control your diarrhea and have a nice life, are you left feeling that the specialist has more important things to do? Like finding and treating cancer, instead of wasting time listing to your complaints? Do you see the physician extender at followup? The frustation on both provider and patient mounts.
In millions of patients the symptoms are not reflected in the findings on x-ray, biopsy or blood test results. You are left with continuing real complaints, problems, symptoms and no real answers or improvement.
I SEE THESE CONSEQUENCES EVERY DAY. I believe the normal testing tells what you do not have. Now we move on to see the actual cause of your problems and what measures might allow you to be better. In fairness "ordinary" physicians are taught our "disease-based" system. Little training seems devoted to unraveling and detecting functional disorders. Further more, insurance companies reimburse problem solving poorly. I was no different for the first 25 years of medical practice.
The MSU article goes on to point out that patients must realize they are not going to be "cured". I'm not convinced; I would implore interested patients in this category to continue seeking the legimate cause of their problems. If the authentic cause can be identified and dealt with, the effects (symptoms) could vanish. I often find abnormalities associated with the digestive tract (GERD, gallbladder problems) or problems with breathing while asleep (obstructive apnea) as genuine causes of far reaching effects through out the body. And in some situations both gastrointestinal and breathing disorders coexist.

Inflammation of the upper airway is very common. Often people complain of recurring sinus infections, laryngitis and "strep throat". Medical terminology tends to pin point the diagnosis based on presenting sign/symptom (laryningitis and hoarseness), or anatomic findings (red throat and pharyingitis) or a combination. The shared pathology does not divvy-up, subdivide or demarcate itself as one would infer after reviewing the International Classification of Diseases. My point is that these maladies are a "blending" of problems dependant on a miriad of circumstances. Seventy eight percent of chronic laryngitis turns out to be related intimately with GERD. The stomach acid need not touch the throat, vocal cords or the sinus cavities to cause the inflammatory reaction.
Stomach acid contacting the lower food tube (as it over flows from the full stomach) triggers a tremendous neural discharge. The acid in the esophagus "startles" the nerve endings of the lower esophagus. Interestingly no heartburn need occur at this point. This reflux event activates the bodily protective apparatus via the "automatic" nervous system, largely through the Vagus nerve. The message is swell, trap, make mucus, leak and squeeze down to stop the further migration of the chemical spill (hydrochloric acid from the stomach). The intensity of the siganal is so urgent that mucus making tissues through the body also hear the call and respond. The intent is to protect the food tube from chemical perforation. The result of a maximal reaction can include massive mucus production to protect the esophagus. If the response is successful no heartburn occurs. BUT the other mucus making tissues may hear the urgent request and also respond. You thus end up with a life saving event for your esophagus that seems like a hassle because the response in other tissues causes pain, mucus, congestion, etc.! If the swelling is most promient in the (tonsil)(larynx)(sinus) it is determined you have (tonsillitis)(laryngitis)(sinusitis) (you fill in the blank). Bacterial, viral, yeast and mixed infections can accompany or follow these protective responses and further complicate the clinical picture. I suspect GERD places such huge demand and stress on our "protective apparatus" there is little reserve to fight off other insults like a "cold or sinus" virus. The regurgitation of harsh digestive juices is so dangerous it seems to overwhelm our protective reservoir. Take this massive insult away by sucessfully treating GERD and our immune system reserves can fend off other troublesome assults. One outcome I see is markedly reduced occurence of viral and bacterial infections such as sore (strep) throat, pharyngitis and sinusitis. This is not yet "proven" but the correlation is very strong. I have documented scores of such individuals.

Sinus problems plague many in our society. The trouble is often blamed on allergies or the weather.The facts reveal that only 1/3 of these folks have allergy. What's up with the other 2/3rds? They may often have problems exactly like allergy BUT they do not respond to Allegra, Clarinex, Zyrtec, etc which are exceedingly effective for allergy. Decongestants give more relief because they shrink swollen membranes regardless of the cause. Thus the addition of a decongestant to the "allergy" medication is called Zyrtec-D for example (D means decogestant).
My experience, since 2000, is that many of these folks have swollen, extremely sensitive mucus membranes as a result of an "alarm" originating elsewhere in the body. This is commonly from the digestive tract due to regurgitation (GERD). Instinctively our body recognizes this event as a chemical spill and thus enormously dangerous and rightly so. The message is SWELL, MAKE MUCUS and TRAP the hazardous foreign invader (good for the digestive tract bad for the sinus cavities!).
The message signal originates remote to the site of the trouble, often in the lower food tube as a result of escaped digestive contents. The Vagus nerve is a big part of this puzzle because it connects many internal organs to effect an "automatic pilot". The mandate from the esophagus is so intense because the nature of the threat is so immense (industrial strength hydrochloric acid "spilling" onto the fragile lining of the esophagus). If the body is completely sucessful at this protective action then no heartburn or indigestion. That's how this can happen WITHOUT heartburn. The esophagus needs all the mucus and protection it can muster but the "signal" is so intense other mucus producing tissues hear the call and respond. The individual ends up without damage to the delicate esophagus BUT has to deal with the mucus, swelling and congestion elsewhere. The manifestation in remote sites where mucus producing tissues are heeding the alarm produces baffling, mysterious problems that seem unjustified. The result is a mucus membrane that is intensely sensitive and intreprets change in temperature, humidity and air quality as "something bad". Viruses and bacteria seem to actually be ensnared and find a home in the mucus rich environment. They incubate, set up house keeping and the body responds with yellow, green and sometimes bloody discharge as infection sets in. Thus antibiotics are often sought by the individual but only provide transient relief. The person is a little less miserable while on antibiotics and that's about as good as it gets. That's where treatment for atypical GERD helps. When successful the regurgitated digestive juices are less harsh, reduced in amount or eliminated. Accordingly the stimulus to produce mucus is reduced or eliminated and a dramatic change can thus occur. Open airways, nomalization of mucus production, reduced/eliminated sneezing, coughing, congestion and headache/facial pain ensue. No "gimmicks"; this is about cause and effect. If the cause is correctly identified and sucessfully treated the effects go away.

Barrett's Esophagus (BE)....carries several acronyms: columnar lined esophagus; Barrett's metaplasia; specialized intestinal metaplasia.
Those of you who know of this condition are aware that it comes to light as the result of endoscopy. The healthy pale, pink lower esophagus has developed a ruddy red appearance, identical to the normal lining of the stomach. This abnormal but characteristic tissue extends from the stomach upward into the lower esophagus. Dr. Norman R. Barrett identified and reported this phemnemon in 1950 as "a tubular stomach". We now believe that the mucus producing internal stomach linining (columnar glandular mucosa) repositions itself beyond its normal upper boundry thus extending into the lower esophagus. It is believed to be the body reacting to the persistent, chronic contact with stomach contents. The condition is confirmed when the biopsy demonstrates tissue that is identical to the lining of the small intestine. This is a troubling finding. It means the esophageal lining has undergone an unhealthy change. Further progression in a "bad" direction results in a condition called dysplasia. In a recent population study 40% of the patients documented to have Barrett's Esophagus DID NOT HAVE HEARTBURN OR INDIGESTION. It is a generally held concept that there is NOT a reliable way to normalize this tissue. However, since 2001 I have documented 19 (nineteen) patients who no longer demonstrate specialized intestinal metaplasia at routine follow-up endoscopy. My clinical impression is that TOTAL supression of extraesophageal manifestations of GERD correlates with a favorable likelihood that the esophagus will heal itself. I published abstracts in The American Journal of Gastroenterology in September 2003 and again in September 2005 to outline 10 cases. The September 2006 American Journal of Gastroenterology published my submission, "Barrett's Esophagus: Regression in 15 Patients" as abstract # 6, on pages 2 and 3 of the Abstract Supplement.