Ulcers and Other Stomach Acid Related Problems

With the holiday season upon us, you may be all to familiar with the prospect of digestive problems like heartburn or stomach pain. While stomach pain and heartburn may only be due to a simple case of overeating, they could be indicative of a more serious problem, like acid reflux or gastrointestinal ulcers. Based on the sales of drugs that treat these symptoms, it is clearly a widespread problem that affects millions of people.  

When we feel stomach discomfort, there are now so many over the counter preparations available to decrease stomach acid and promise you relief that it is easy to just pop a pill and ignore the possibility of a more serious underlying problem. Unfortunately, approaching stomach pain or digestive problems by simply masking the symptoms can lead to increasingly severe problems. Furthermore, are these medications even safe to use?


Gastroesophageal Reflux - A Fancy Name For Heartburn

Reflux is simply when stomach acid is forced back up into the esophagus (the tube in which food goes down to the stomach) where the acidity causes damage to the cells (epithelial cells) lining the esophagus. This is typically experienced as a burning sensation in the chest called heartburn. If the esophagus is continually exposed to stomach acid, then permanent damage such as scarring can be done to these cells. This can lead to serious problems later on.

Besides pain and discomfort, the long term consequences of gastroesophageal acid reflux appear to be fourfold.

• Reflux esophagitis is probably the most common disorder most people are familiar with, though most people simply call it “heartburn”. The burning sensation you feel in your chest is quite literally your stomach acids burning the lining of your esophagus. In the short term, this is painful. In the long term, serious problems may develop. Stomach acid can cause scarring of the esophagus, killing off the epithelial cells and leaving scar tissue in its place. This type of heartburn can also lead to ulceration (an open wound) of the esophagus in the short or the long term.

• Esophageal Strictures are a buildup of scar tissue in the esophagus from repeated exposure to stomach acid, often from acid reflux. The normally very flexible esophagus slowly becomes fibrous and the scar tissue narrows the esophageal pathway (to the size of a pencil or smaller), preventing food from naturally passing to the stomach. Suddenly, large pieces of food can become serious blockages that may even require surgery to remove. Even a small piece of food can become a plug that prevents other food from reaching the stomach. Strictures are extremely painful and difficult to manage. The worst case scenario for strictures is that the esophagus actually tears and causes large amounts of internal bleeding, which can be fatal.

• Barrett’s Esophagus is a very strange and dangerous complication of chronic acid reflux. Essentially, the body senses acid so often in the lower section of esophagus that the epithelial cells there actually begin to change (called metaplasia). They morph into cells exactly like the ones in the start of the small intestine (where the stomach acid usually goes after the stomach). While this process makes the cells more resilient against damage from stomach acid, the metaplasia increases the risk of very serious cancers.

• Esophageal adenocarcinoma is a rare cancer caused by the above problems.

Helicobacter pylori - The Ulcer Maker

Ulcers are basically an open wound in your stomach.

Not too long ago, most doctors and health care practitioners thought that ulcers were caused by stress, but we now know that the primary cause of ulcers is a bacterium called Helicobacter pylori (H. pylori). H. pylori is found in just over 50% of people, making it the most widespread infection in the world, though only 20% of people infected ever show symptoms.

Most people with an H. pylori infection will never have any signs or symptoms. It's not clear why this is, but scientists believe some people may be born with more resistance to the harmful effects of H. pylori. In addition, H. pylori has many different bacterial strains which have been found to differ by as much as 6% of their DNA nucleotides.

When signs or symptoms do occur with H. pylori infection, they may include:

• An ache or burning pain in your abdomen
• Nausea
• Vomiting
• Frequent burping
• Bloating
• Weight loss

If you have experienced these symptoms for a while, there is a good chance that you may have an H. pylori infection and, fortunately, there are several ways of testing for it. The easiest ways are to test blood (for antibodies) or urine (using the “ELISA” test). These two methods are fairly accurate (75-80%) and easy to do if you suspect an infection. There are other, more involved tests for H. pylori including a stool antigen test, carbon urea breath test (in which you burp up specially tagged Carbon Dioxide), and finally an endoscopic biopsy (a tube down your throat taking samples of the cells of your stomach wall).

A typical endoscopic procedure in the stomach.

You should make an appointment with your doctor if you notice any of the persistent signs and symptoms that we’ve mentioned. Seek immediate medical help if you experience any of the following symptoms:

• Severe or persistent abdominal pain
• Difficulty swallowing
• Bloody or black tarry stools
• Bloody or black vomit or vomit that looks like coffee grounds

H. pylori can cause serious damage to the lining of the stomach. In an attempt to protect itself from the acids naturally found in our stomachs (for digesting food), the bacteria dig their way into the thin layer of mucus that protects the stomach walls. Once there, the bacteria produce chemicals that neutralize acid (to make it more hospitable to them). One of these chemicals reacts with the gastric acids and produces ammonia, which is highly toxic to the cells lining the stomach. The damage to the cells of the stomach walls provokes an immune system response, causing inflammation, which (ironically) makes the cells even more vulnerable to stomach acid. The majority of H. pylori strains in the western world (50-70%) have a gene which causes increased inflammation, making ulcers and cancer even more likely to develop.

H. pylori can cause the stomach to react by either producing too much or too little stomach acid, both levels making ulcers more likely to develop.

With rising rates of antibiotic resistant strains of H. pylori, the treatments for a severe infection are becoming less effective. For more information on antibiotic resistance and how you can prevent it, please read our previous post on the topic.

Medications

Medications used to treat these digestive problems are among the most prescribed of any class of drugs. Just like the symptoms associated with the problems of stomach acid, the medications come in many forms. Some slow down or halt the production and excretion of stomach acid. Others simply neutralize the acid already in the stomach. The medications all seek to achieve the same goal of lowering the acidity of the stomach to reduce symptoms and complications.

The problem is that your body needs a certain amount of acid to digest certain foods, especially meat. If you lower the acidity too much, your body might not get enough of vital nutrients like vitamin B12, calcium, and many types of protein. In addition, lowering the acidity of the stomach removes one of the key defenses your body has against food born illness. Most of the time, if you eat a microbe, your stomach will simply destroy it with digestive acids. If your medication lowers the acidity of your stomach, the microbe can more easily just pass right through and make a new home of your intestines, potentially leading to dysbiosis or a serious infection.

There are dozens of different types of over the counter
remedies for treating the symptoms of stomach problems.

These medications should be used sparingly, if possible, to prevent complications.

Antacids are used to chemically lower the acidity (increase the pH) of the stomach, providing direct relief to the burning sensation of stomach acid. They can be taken before or after eating and are effective at relieving unexpected heartburn or burning sensation in the stomach. Antacids are found at any drug store, pharmacy, market, truck stop, and corner store just about everywhere. For short term relief of an unexpected problem, they are very useful and easy to find in a pinch.

Though antacids are generally safe, there are some side effects to the different formulations. Most antacids are either sodium bicarbonate (yes, baking soda) or, more commonly, calcium carbonate. Using these antacids for a long period of time can lead to kidney stones. If the antacids are calcium carbonate, there is a risk of developing hypercalcaemia (too much calcium) if you use them often enough. Older antacids were made up of aluminum hydroxide, which has its own risks, not the least of which is that aluminum is neurotoxic. In addition, aluminum hydroxide can also cause constipation.

H2 blockers were the first of the “blockbuster drugs” developed. The first of them, Tagament, was developed and marketed in the 1960s and was a huge financial success. Technically, H2 blockers are antihistamines, preventing the secretion of acid in the stomach. H2 blocking drugs typically only work in about 50% of patients.

These have pretty much been succeeded by Proton Pump Inhibitors (PPIs), but a few of these are still on the market and some are sold over the counter. Pepcid and Zantac are the two biggest name drugs in the H2 blocker category.

Proton Pump Inhibitors (PPIs) are the newest and most effective prescription drugs for managing stomach acid. They work in an extremely targeted way by preventing stomach acid from even forming in the first place. The effects of a single dose can last for days.

Nexium, the "little purple pill" is one
of the heavily marketed "blockbuster"
drugs for treating acid reflux.

Even though they are highly targeted drugs with very few side effects, the intended effect (limiting stomach acid) has some associated problems.

Proton pump inhibitors have been linked to:

• increased risk of community acquired pneumonia (also true of H2 blockers).
• increased risk of Clostridium difficile infection (1.7x after a singe use, 2.4x after multiple uses).
• a rebound effect of increased acid production when stopped after taking regularly.
• long term use may cause low serum magnesium levels.

These types of drugs should not be used long term without doctor’s supervision because of these issues.

Antibiotics are primarily used to treat an H. pylori infection. The standard treatment for an H. pylori infection is a triple therapy cocktail of amoxicillin and clarithromycin (both antibiotics), and a proton pump inhibitor, usually Prilosec (omeprazole), for one week.

Complementary and Alternative Medicine (CAM)

CAM practitioners look at these problems not as a primary problem, but as a secondary symptom of your overall health. CAM treatments work to strengthen your immune system, help your body to function more normally, and will also use natural antimicrobials to help fight off an infection of H. pylori.

There are a number of antimicrobial treatments available that may help with an infection such as H. pylori. CAM treatments using antimicrobials may take longer to treat an infection, but the side effects and risks are often much lower than using antibiotics.

Don’t be afraid to ask

The only way to know if these antimicrobial treatments work to kill the H. pylori infection is to run one of the standard tests for an infection. Many doctors, allopathic and CAM, don’t consider running these tests essential. Often, health care practitioners treat based on symptoms, once the symptoms resolve, they consider the illness gone. While this is an acceptable clinical practice, it is important to understand that without formal testing, there is no way to actually know if you had H. pylori or if it has been killed. In most cases, this doesn’t matter because if your symptoms resolve, then that generally suggests that there are no serious long term risks or consequences. Talk to your health care practitioner about the potential risks and benefits of antibiotic and CAM antimicrobial treatments for H. pylori so that you can make a wise decision for yourself.

When dealing with problems in the gut, it is important to get a correct diagnosis and not just mask the symptoms. It’s easy to just pop a pill and forget about the problem, but that potentially leads to more problems down the road. Unless your health care provider understands the underlying problem, you could simply be masking symptoms while the real problem gets worse. Don’t be afraid to ask what the underlying problem causing your symptoms is and what all of the options are to treat it.

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Researched and written by Dr. Rebecca Malamed, M.D. with assistance from Mr. Malcolm Potter.