Dr. Kurt Barrett's GERD Blog - GERD and Respiratory Problems

Why Didn't MY DOCTOR tell me?

nospam@example.com (Kurt Barrett, D.O.) — Sun, 04 Apr 2010 05:39:43 -0700

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!

Proton-Pump Inhibitor Therapy in Poorly Controlled Asthma

nospam@example.com (Kurt Barrett, D.O.) — Sat, 09 May 2009 18:31:52 -0700

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).

GERD, Asthma, and other Respiratory Problems

nospam@example.com (Kurt Barrett, D.O.) — Tue, 05 May 2009 06:25:01 -0700

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

nospam@example.com (Kurt Barrett, D.O.) — Tue, 05 May 2009 06:03:29 -0700

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

GERD Common in Patients with COPD (emphysema)

nospam@example.com (Kurt Barrett, D.O.) — Sat, 13 Dec 2008 21:59:38 -0700

The June 2007 issue of Chest reported more than half of the patients with advanced COPD (chronic obstructive pulmonary disease) have GERD (gastroesophageal reflux disease). The overall presence of GERD was 57% in this small 42 patient study. Only 26% reported heartburn or acid indigestion. Most were not recieving acid blockers at the time of their referral to the University of Minnesota School of Medicine. Even though they did not advise routine screening for GERD in emphysema, I do. An even more recent study confirmed a positive correlation involving GERD worsening breathing problems. From MEDSCAPE, "NEW YORK (Reuters Health) Nov 26, 2008 - Results of a study published in the November issue of Thorax suggest that symptoms of gastroesophageal reflux disease (GERD) are an important factor associated with exacerbations in chronic obstructive pulmonary disease (COPD)."

Asthma

nospam@example.com (Kurt Barrett, D.O.) — Sat, 22 Jul 2006 18:04:27 -0700

Asthma is common and the incidence is rising in all age groups. Gerd is likewise common and on the rise. Not all of the asthma patients have heartburn, but the MAJORITY will have GERD. This will likely shock you but up to 80% of asthma patients will manifest GERD by symptoms or by testing. Up to 80% of that group of asthma patients can obtain signifigant improvement and relief of their symptoms with appropriate therapy for atypical GERD. This means that of 100 asthma patients 64 could obtain substantial improvement IF treated aggressively for GERD. This may seem far fetched to the casual observer. This information is not speculation but fact. "Acid Related Diseases" by I. Modlin and G. Sachs, second edition,on page 400 starts the discussion of asthma and the relationship to GERD.
The national asthma guidelines DO NOT reflect this information. At best they mention GERD, treating it as a curiousity. There are a whole series of unapparent reasons why a common therapy, generally considered very safe, with up to 80% improvement in over half of afflicted patients is given so little publicity. I won't go too far in speculating why this therapy is so slow to disseminate except to decry the compartmentalization of modern medicine. Why hasn't my doctor talked to me about this? Your doctor probably has not prioritized this topic for self study is the likely explanation. They are innundated with topics to stay current on. We as physicians often look to specialists to influence our knowledge and resultant treatment. The last seminar I attended barely touched on manifestations of GERD beyond the obvious digestive complaints. When the gastroenterologist spoke on GERD, heartburn was the topic emphasized and if quized about asthma the lecturer would respond,"I don't treat lungs". When the pulmonary specialist is approached about GERD/asthma the response I encounter is "I don't treat stomach diorders". Thus the patient lacks an advocate and often becomes "a man without a country".
Since 2000 I have been increasingly conscious of the improvement in patient symptoms while treating atypical GERD. Decreased cough, less wheezing, improvement in sleeplessness, elimination of excessive mucus and reduction in congestion are common. The most profound improvement has been in eliminating infections and thus avoiding antibiotics. This lack of need for recurrent antibiotics is dramatic and quite remarkable. Antibiotics are not being rationed or withheld. They just are NOT needed.