"Acid Reflux and Ulcers,"

Dr. David Peura, University of Virginia Health System, on-line chat with www.AmericasDoctor.com, June 16, 2000.

Moderator: Hello and welcome to this evening's Q&A discussion "Acid Reflux and Ulcers" with Dr. David Peura. Dr. David Peura has been a professor of medicine and associate chief of the Division of Gastroenterology and Hepatology at the University of Virginia Health System since 1996. A former consultant to the U.S. Army Surgeon General, he is a leading expert on the Helicobacter pylori bacterium, or H. pylori. A member of numerous professional organizations, Dr. Peura has served as chairman of the Board of Governors and as a trustee for the American College of Gastroenterology and as chairman of the education committee for the American Gastroenterological Association. Dr. Peura is a member of the National Digestive Health Initiative (NDHI) steering committee and directed the NDHI public education campaign for H. pylori sponsored by the American Digestive Health Foundation. Without further delay Dr. David Peura...

Dr. Peura: Welcome this evening. We are going to be talking about a very common problem that most of you or many of you suffer from or know people who suffer from: heartburn, indigestion and ulcers. Please feel free to ask any questions you might have, but remember on specific things you are really going to have to see your doctor.

Guest: Does reflux inevitably lead to ulcer?

Dr. Peura: Reflux and ulcer disease really are two different things. Both are caused by acid, but ulcers in addition are usually associated with an infection, a bacterium called H. pylori. Getting rid of the bacteria can cure ulcers, but it does not do anything for heartburn.

Guest: Does stress cause ulcers? If so what can treat the ulcer?

Dr. Peura: Stress does not cause ulcers. Stress makes symptoms worse or makes someone more aware of their symptoms. As I noted earlier, many ulcers are caused by an infection. Treating the infection treats the ulcers. Eliminating acid treats the symptoms.

Guest3: Can seasonal allergies exacerbate acid reflux?

Dr. Peura: It is interesting that allergies can make reflux symptoms worse in some individuals. If they have a lot of stuffiness or postnasal drip, people tend to swallow more and as a result they accumulate more air in their stomachs and venting this air may promote reflux.

Guest: Why do stressed-out people always seem to get ulcers? Is it something mistaken as an ulcer?

Dr. Peura: Stressed-out people often are more aware of aches and pains symptoms in general. Probably, their ulcers are more frequently diagnosed because they complain of their symptoms to their doctors. Alternatively, their symptoms may be due to other things other than ulcers brought on by a "stressful lifestyle" - smoking, eating too quickly, eating bad things, not taking time out for exercise to name a few. There are lots of people with stress that don't have ulcers.

Guest: Can surgery be done on an ulcer?

Dr. Peura: Surgery used to be done quite frequently for ulcers, but now that we have good medicines to treat the infection that causes most ulcers, or to reduce acid which causes most ulcer symptoms, surgery is done much less frequently. Surgery now is done primarily for complicated ulcers: those that bleed, develop scar tissue that interferes with the emptying of food from the stomach, or the ulcers that erodes through the lining of the intestines.

Guest2: What tests are available to diagnose acid reflux?

Dr. Peura: The best test for diagnosing acid reflux is a response to treatment. If you have symptoms that suggest heartburn, your doctor may choose to treat you with medicine to suppress acid. If this works quickly and predictably, then your impression and the doctor's impression that you have reflux is most likely correct. If you don't respond to that test, your doctor can order specific x-rays, a procedure called endoscopy where he or she can look into your esophagus to check for irritation or damage or actually do a study called PH monitoring to determine if the acid is actually coming up into the esophagus. We are using these tests less often now than we did in the past since we have such effective therapy to treat reflux symptoms.

Guest3: Are Heidelberg capsules used to diagnose or determine appropriate treatment for acid reflux?

Dr. Peura: I am not familiar with that particular Heidelberg capsule.

Guest: Can surgery be used on reflux problems?

Dr. Peura: Surgery is an alternative treatment for reflux. We generally reserve surgery for people who are poorly responsive to medicine or find it hard to take medicine for one reason or another. Before surgery is done, however, specialized tests should be ordered such as endoscopy to look at the esophagus, a PH monitoring to confirm reflux is present, and a motility test to ensure that the esophagus is working properly.

Guest: Can over-the-counter antacids be over used or abused? I know they aren't abused as a drug but maybe depended on?

Dr. Peura: Over-the-counter medications are medicines and like any medicine that can have side effects associated with them. They should be used as instructed on the package. If someone needs to use them in larger quantities or for longer periods of time than recommended, then he or she should consult their physician since there may be other better medications to treat the symptoms. Recently the National Heartburn Alliance (NHBA), a group of doctors and health care providers, has addressed some of these issues relating to symptoms and medicines. Anyone who would like a free brochure outlining the dos and don'ts of heartburn can call 1-800-NHBA-INFO.

Guest: What lifestyle changes should be taken to avoid heartburn?

Dr. Peura: Lifestyle does not cause all heartburn. Heartburn is due to acid coming up from the stomach into the esophagus. Doing certain things such as avoiding large meals, fatty foods, chocolate, peppermint, avoiding lying down after meals, can all help prevent acid from coming up the esophagus and reduce heartburn. Losing weight, moderate exercise, not smoking is also helpful in some people in improving heartburn symptoms. But I need to emphasize that frequent heartburn more than three or four times per week can signal a more severe problem and should not be treated only with changes in lifestyle. Medications, even over-the-counter medications, may be necessary in this situation.

Guest2: Is there another test that can be done to diagnose acid reflux other than the endoscopy procedure?

Dr. Peura: As I noted previously, the best test to diagnose heartburn or reflux is a trial of treatment to suppress acid. This actually turns out to be better than endoscopy.

Guest3: What is your opinion regarding the relative efficacy of Prilosec® as compared to Pepcid® or other prescription medicines to treat reflux?

Dr. Peura: Prilosec is in a class called proton pump inhibitors. There are now four medicines in this class. They are the most effective treatments available for reflux. Pepcid is in a class of drugs called H2 blockers. These drugs are also effective in treating symptoms, but they are not as strong as the proton pump inhibitors.

Guest6: I just had an esophagram done and they found I have a small ulcer. What can be done about that?

Dr. Peura: It is difficult to give you a specific recommendation because I do not know the size and exact location of the ulcer. However, if the ulcer is in the esophagus, it may be due to reflux of acid and treatment with a proton pump inhibitor may help it heal. However, you need to check with your doctor about undergoing an endoscopy to actually look at the ulcer and biopsy it if needed.

Guest2: I am presently taking two Prilosec at bedtime, but I still have problems getting very sick at night.

Dr. Peura: Again, it is difficult to give you a specific recommendation. However, the proton pump inhibitors like Prilosec appear to be most effective when given before a meal. Generally, if they are dosed twice daily, one is taken before breakfast and one before the evening meal. Taking two at bedtime may not be the most effective way to dose the drug. You need to check with your doctor for more specific recommendations, especially since you are continuing to have symptoms despite two doses a day.

Guest3: What are the other three proton pump inhibitors so that I may investigate their relative merits with my physician?

Dr. Peura: The four proton pump inhibitors are Prilosec, Prevacid, Aciphex®, and Protonix®. Given in equivalent doses, studies suggest that they are all effective, and all very safe.

Moderator: Are there any further questions concerning reflux, heartburn, or ulcers for Dr. Peura?

Dr. Peura: For people that are interested in general information about heartburn, what causes it, what you can do to help treat and prevent it can call 1-800-NHBA-INFO for a free consumer brochure. This is put out by the National Heart Burn Alliance, which is a group of physicians and other health care providers that are joining together to provide credible information about heartburn and its treatment. This is particular important because heartburn is such a common problem effecting 20 to 40 percent of adult Americans.

Moderator: I have difficulty swallowing solid food. My doctor says it is due to reflux; what can I do?

Dr. Peura: Your doctor is correct that difficulty swallowing can be due to reflux. Acid that has come into contact with the esophagus over a long period of time can lead to scar tissue formation and narrowing. However, difficulty swallowing can also be a sign of cancer. So that anyone with this complaint needs to check with the doctor and consider having an x-ray study or having an endoscopy performed before treatment for reflux is initiated.

Guest3: Is there any correlation between acid reflux severity and cancer of the esophagus?

Dr. Peura: A recent study published in the New England Journal of Medicine which was done in Sweden suggested that people who have frequent heart burn, more than three to four times per week, heartburn that has been going on for many years, more than 5 to 10 years, and those with particularly severe symptoms were at higher risk of developing cancer of the esophagus. That is why people with frequent severe symptoms that have been going on for a long period of time need to consult their doctor for advice in managing their problem. Hopefully this will prevent the development of subsequent cancer.

Guest6: What is a proton pump inhibitor you mentioned?

Dr. Peura: A proton pump inhibitor is a class of medicine that inhibits the stomach's acid reduction. The stomach makes acid every day in response to eating or even thinking about eating. This acid is very corrosive, much like battery acid and if it washes back into the esophagus, it can cause irritation and heartburn. Proton pump inhibitors prevent the acid from being produced in the stomach. Therefore, they can treat reflux-related irritation and symptoms.

Moderator: Since there are no further questions I will get Dr. Peura's closing remarks...

Dr. Peura: Since there are no further questions, we can end this session a bit early. There is never a good time to suffer from heartburn or from ulcer symptoms. However, in this day and age we have good medication not only to treat heartburn symptoms, but good antibiotics to cure the infection that causes ulcer disease. Heartburn and indigestion are not a normal way of life. There is no reason that anyone needs to suffer. Consult your doctor because there is good medication available for your problem. Good night and be careful out there. Thank you.

Moderator: Thank you for joining evening's Q&A discussion, "Acid Reflux and Ulcers" with Dr. David Peura. Dr. David Peura has been a professor of medicine and associate chief of the Division of Gastroenterology and Hepatology at the University of Virginia Health System since 1996. A former consultant to the U.S. Army Surgeon General, he is a leading expert on the Helicobacter pylori bacterium, or H. pylori. A member of numerous professional organizations, Dr. Peura has served as chairman of the Board of Governors and as a trustee for the American College of Gastroenterology and as chairman of the education committee for the American Gastroenterological Association. Dr. Peura is a member of the National Digestive Health Initiative (NDHI) steering committee and directed the NDHI public education campaign for H. pylori sponsored by the American Digestive Health Foundation. Thank you all once again for joining our chat. Have a nice evening!