2 comments Wednesday, December 16, 2009

Gastroesophageal reflux disease (GERD) is defined as the pathological retrograde movement of gastric contents into the esophagus. Various esophageal motility disturbances which may be important in reflux are observed in patients with GERD. The main esophageal motility disorder in these patients is ineffective esophageal motility (IEM). Increased acid clearance time and IEM have been shown to be strongly associated with isolated proximal reflux. However, there are no data that conclusively link motility disorders with isolated distal reflux (IDR).

A research team, led by Dr. Yasemin Ozin from Turkey Yuksek Ihtisas Training and Research Hospital investigated manometric measurements in patients with IDR and compare the findings in individuals with and without erosive esophagitis.

Their study was published in the World Journal of Gastroenterology. In their study, patients with symptoms of GERD were evaluated with esophageal manometry, 24-h ambulatory pH monitoring, and upper gastrointestinal endoscopy. Among patients with isolated distal reflux, the manometric findings of patients who had erosive disease and non-erosive disease were compared. There were no significant differences between the isolated distal reflux group and control group with respect to age, body mass index, and esophageal body contraction amplitude. Mean lower esophageal sphincter pressure was significantly higher in the control group. There were no differences between the erosive reflux disease and non-erosive reflux disease subgroups with respect to mean esophageal body contraction amplitude (EBCA), lower esophageal sphincter pressure, or DeMeester score. However, IEM was observed only in patients with erosive reflux disease.

The authors provided more insight into the pathophysiology of reflux disease. The finding of very low EBCA being observed only in patients with erosive disease might be helpful in identifying these patients.

Reference: Ozin Y, Dagli U, Kuran S, Sahin B. Manometric findings in patients with isolated distal gastroesophageal reflux. World J Gastroenterol 2009; 15(43): 5461-5464 http://www.wjgnet.com/1007-9327/15/5461.asp

Source: Ye-Ru Wang
World Journal of Gastroenterology


Gastroesophageal reflux (GER) is a common problem in mechanically ventilated patients and contributes to the development of esophageal mucosal injury and even erosive esophagitis. The relationship between percutaneous endoscopic gastrostomy (PEG) and subsequent development of GER is complex and not well understood.

A research article published in the World Journal of Gastroenterology addresses this question. The research team from Greece explored the factors that interfere with failure of PEG to reduce GER in critically ill, mechanically ventilated patients.

A cohort of 29 consecutive mechanically ventilated patients undergoing PEG was prospectively evaluated. The patients were divided into 2 groups based on whether GER decreased to less than 4% (responders, RESP group) or remained unchanged or worsened (non-responders, N-RESP group) after PEG placement. Reflux esophagitis and the gastroesophageal flap valve (GEFV) grading differed significantly between the two groups.

The researchers drew a conclusion that gastroesophageal reflux is not a contraindication for PEG tube placement. By identifying the factors that predict failure of PEG to decrease GER, their study may represent a reference in deciding which patients are likely to benefit from PEG tube placement and thus protect them from the development of esophagitis and even ventilator-associated pneumonia.

Reference: Douzinas EE, Andrianakis I, Livaditi O, Bakos D, Flevari K, Goutas N, Vlachodimitropoulos D, Tasoulis MK, Betrosian AP. Reasons of PEG failure to eliminate gastroesophageal reflux in mechanically ventilated patients. World J Gastroenterol 2009; 15(43): 5455-5460 http://www.wjgnet.com/1007-9327/15/5455.asp

Source: Ye-Ru Wang
World Journal of Gastroenterology


Stomach acid may only be part of the problem when it comes to esophagus injury related to gastroesophageal reflux disease (GERD). A new study suggests that an immune system response may be the real culprit behind reflux esophagitis.

Researchers say it's been assumed that reflux esophagitis develops when cells in the lining of the esophagus become burned and damaged by stomach acid backing up into the esophagus.

But in a rat model of GERD, researchers found that this acid reflux didn't directly damage the lining of the esophagus. Instead, the acid triggered the release of chemicals called cytokines that attract inflammatory immune cells to the area, which were responsible for the real damage.

If further studies in humans confirm these results, researchers say new GERD treatments that target this immune response may be needed to effectively manage the disease.

"Currently, we treat GERD by giving medications to prevent the stomach from making acid," says Rhonda Souza, MD, associate professor of internal medicine at the University of Texas Southwestern Medical Center, in a news release. She says "maybe we should create medications that would prevent these cytokines from attracting inflammatory cells to the esophagus and starting the injury in the first place."

In the study, published in Gastroenterology, researchers created GERD in rats by performing an operation to connect the duodenum (first section of the small intestine) to the esophagus, allowing stomach acid and bile to enter the esophagus.

The results showed damage to the lining of the esophagus did not occur immediately after exposure to the stomach acids. It happened weeks later.

"That doesn't make sense if GERD is really the result of an acid burn," says researcher Stuart Spechler, MD, professor of internal medicine at UT Southwestern, in the news release. "Chemical injuries develop immediately. If you spill battery acid on your hand, you don't have to wait a month to see the damage."

Within three days after the operation, researchers found no damage to the cells on the surface layer of the esophagus, but they found inflammatory cells in the deeper layers. Those inflammatory cells rose to the surface three weeks later after the initial stomach acid exposure.


0 comments Tuesday, September 15, 2009

Irritable Bowel Syndrome Pain Bad, Stigma Worse

People with IBS suffer pain and greatly reduced quality of life -- but what hurts most is when family, friends, and doctors don't think their suffering is legitimate.

Irritable bowel syndrome greatly disrupts the lives of people who suffer from it. But unlike other gut diseases, such as inflammatory bowel disease, IBS has no known physical cause. And it presents in different ways: with unpredictable diarrhea, with extreme constipation, or both.

"IBS is a disorder with no structural abnormality like ulcers or cancers so it takes on a lower level of legitimacy for doctors and patients," IBS expert Douglas A. Drossman, MD, tells WebMD. "People say it isn't real, and patients say, 'Well then, I must be crazy.'"

That would be a lot of crazy people. An estimated 7% of the U.S. population has IBS. In the U.K., the estimate is even higher: about 10% to 20% of the population.

Lacking a yardstick, doctors have had a hard time judging IBS severity. The FDA recently ruled that new IBS treatments must be evaluated in terms of whether patients feel better. But what do patients say IBS is like?

"Nobody was looking at how patients characterize their illness," says Drossman, co-director of the University of North Carolina Center for Functional GI and Motility Disorders.

So Drossman and colleagues designed two studies. In one, the researchers enrolled 32 IBS patients in small focus groups. In the other, Drossman's team performed an international survey of nearly 2,000 people with an IBS diagnosis.

As expected, patients reported bowel symptoms:

  • 80% experienced pain.
  • Three-fourths of patients reported bowel difficulties.
  • Half of the patients with diarrhea-predominant or mixed-type IBS reported fecal incontinence.
  • Nausea, muscle pains, and, for those with diarrhea, gas, mucus in stool, and belching were common.
  • More than two-thirds of patients reported bloating.

But just as common -- and, as the focus group members reported, at least as bothersome -- was the way IBS affected their daily function, their thoughts, and their feelings.

"The impairment in their life was far greater than you would imagine -- their own sense of degradation and the stigma they experience from others," Drossman says. "Even when they are not symptomatic, the condition still pervades their life and how they think and feel about it."

IBS: Uncertainty, Loss Add to Suffering

Stigma from friends, family, and doctors was a dominant theme, Drossman found. Patients often said that nobody understood what they were going through or truly believed they were ill. This created as great a barrier to daily function as the disease itself.

Another major theme was uncertainty, a sense of having no control over the condition. Most patients end up greatly restricting their daily activities, which results in a sense of loss: loss of freedom, loss of spontaneity, and loss of social contacts.

All of this leads to emotional responses: fear, shame, embarrassment, and degradation. A big issue, Drossman says, is that patients refrain from sex because of fear of incontinence or other symptoms -- thus straining their relationship with their spouse.

To get a measure of the extent of this suffering, the Drossman team's survey asked IBS patients what they'd give to be free of their symptoms. On average, they said they'd give up a fourth of their remaining years of life.

There isn't a cure for IBS. But treatment can be effective. Drossman says that 90% of the treatment is helping people understand their condition and come to feel they can manage it.

"The feelings of fear, distress, and frustration may be generic and affect all people with IBS, but how people deal with those feelings varies," he says. "In addition to all the disease management aspects, we focus on understanding where the patients are, validating their experience, and helping them move forward. It is a focus on the person with the condition, and not on an organ."



Researchers in England may have found a new way to treat colitis and other inflammatory bowel diseases.

Those scientists took a bacterium called Bacteroides ovatus, which people naturally have in their gut, and genetically altered it to secrete a protein called KGF-2 when exposed to a sugar called xylan.

The point is to bump up the presence of KGF-2, which is a human growth factor that could help heal damage done by inflammatory bowel diseases.

Why not just give human growth factors directly? Because "they are unstable when administered orally and systemic administration requires high doses, increasing the risk of unwanted side effects," the researchers write in the online edition of the journal Gut.

Their study focused on mice with colitis, a type of inflammatory bowel disease. The scientists gave the genetically engineered bacteria orally to some of the mice every other day, and also laced the drinking water of some of the mice with xylan. For comparison, other mice didn't get the bacteria and/or the xylan drink.

Compared to the other mice, the mice treated with bacteria and xylan had a reduction in rectal bleeding, inflammation, and weight loss; they also had faster healing of colitis-damaged tissue and an improvement in their stool consistency.

Tests need to be done in people, and one of the researchers, Simon Carding, PhD, discussed the treatment with WebMD via email. Carding is a professor of mucosal immunology at England's University of East Anglia Medical School and the director of integrated biology of the gastrointestinal tract research program at the Institute of Food Research in Norwich, England.

Carding writes that the bacteria used "are present in the gut of everyone, so patients will be taking something that they already have and the treatment should be well tolerated. The outstanding questions concern formulation and dosing protocols, which we plan to address as part of our phase of studies."

It might be possible to do a short, one-time bacteria dosing regimen that would establish a permanent colony of the genetically engineered bacteria. Another option would be to establish a temporary colony, repeating those treatments when the disease flares up.

Carding says natural sources of xylan -- tree bark, rice husks, and oat kernels -- aren't commonly found in the diet, so patients would need to supplement their diets with xylan, such as in a drink.

"Animals tolerate high concentrations of xylan [in] their drinking water very well and have never exhibited any adverse signs from excessive xylan consumption," Carding writes.

Carding notes that the bacteria strategy could be used to treat various gut diseases, including delivering agents to interfere with the formation of new blood vessels that feed intestinal tumors and delivering vaccine antigens to build the gut's immunity against viruses, bad bacteria, and infection.


Proton pump inhibitors are highly effective treatments for acid reflux symptoms, but taking prescription-strength dosages of the drugs for just a few months can lead to dependency, new research suggests.

Healthy adults in the study with no history of acid reflux symptoms -- such as chronic heartburn, indigestion, or acid regurgitation -- developed such symptoms when they stopped taking the drugs after eight weeks of treatment.

The findings provide the best evidence yet that withdrawal from acid-blocking proton pump inhibitor (PPI) therapy is associated with a clinically meaningful increase in acid production above pre-treatment levels, researchers say.

PPIs like Aciphex, Prilosec, Prevacid, Nexium, and Protonix are among the most widely used prescription medications in the world. By one estimate, 5% of adults in developed countries take the acid-reducing drugs.

“We have known for years that long-term treatment with PPIs induces a temporary increase in the secretion of acid, but the thinking has been that this probably wasn’t clinically relevant,” lead researcher Christina Reimer, MD, of Copenhagen University tells WebMD.

PPI-Related Rebound

Reimer and colleagues recruited 120 healthy adults with no history of acid reflux disease for the study.

Half the study participants were treated with daily 40 milligram doses of the PPI Nexium for eight weeks, followed by four weeks on a placebo. The rest took a placebo pill throughout the 12-week trial.

Each week, the participants completed a standardized questionnaire designed to rate the severity of gastrointestinal (GI) symptoms.

Although symptoms were similar in the two treatment groups at the start of the study, a big difference in symptoms was seen in the weeks after the active treatment group stopped taking the PPI.

In the PPI group, 44% reported at least one acid-related symptom in weeks nine through 12, compared to 15% of the placebo group.

By week 12, when the PPI group had been off active treatment for four weeks, about 21% reported symptoms of heartburn, indigestion, or acid regurgitation, compared to slightly less than 2% of those who never took a PPI.

The study appears in the July issue of the journal Gastroenterology.

Calls to study participants three months after PPI treatment was stopped confirmed that these symptoms had resolved, Reimer says.

“We don’t know how long this rebound effect lasts, but we can say that it is somewhere between four weeks and three months,” she says.

This rebound is theorized to the result of an overproduction of the stomach acid-stimulating hormone gastrin in response to PPI-related acid suppression.

When the medication is stopped, the extra gastrin in the blood signals the stomach to work overtime to produce acid. When gastrin levels return to normal, acid secretion slows, writes Reimer.

“PPIs Over-Prescribed”

Reimer says the phenomenon, known medically as rebound acid hypersecretion, is not likely to occur in people who take the over-the-counter version of the PPI Prilosec for short periods.

She adds that the benefits of PPI treatment still appear to far outweigh the risks for patients with established acid reflux disease.

“Most patients with acid reflux disease need an acid-suppressing drug and they should not be concerned about this,” she says. “But millions of people are prescribed these drugs for uncertain indications and in these patients we run the risk of inducing the symptoms that these drugs are used to treat.”

PPI researcher Kenneth McColl, MD, of the University of Glasgow, tells WebMD that the drugs are now widely prescribed for a host of upper GI complaints even though there is little evidence that they are effective for these uses.

“It is clear that doctors need to be more selective in prescribing these drugs,” he says. “They should not be given to patients with upper GI symptoms on the off chance that the symptoms are acid related.”

In response to the study, a spokesman for AstraZeneca Pharmaceuticals, which markets Prilosec and Nexium, questioned the study design and its relevance to patients with acid reflux symptoms.

“This study was conducted in healthy volunteers, and the authors acknowledge that they can’t be sure that the conclusion can be carried over to patients who have started PPI therapy because of dyspeptic symptoms,” Blair Hains tells WebMD.

Hains cited a 2007 review of research examining rebound acid hypersecretion, which concluded that there was not strong evidence that withdrawal from PPIs is associated with a clinically relevant increase in acid production.

Calls to Takeda Pharmaceuticals, which manufacturers Prevacid, were not returned by publication time.




Indigestion is often a sign of an underlying problem, such as gastroesophageal reflux disease (GERD), ulcers, or gallbladder disease, rather than a condition of its own.

Also called dyspepsia, indigestion is a term used to describe a feeling of fullness or discomfort during or after a meal. It can be accompanied by burning or pain in the upper stomach.

What Are the Symptoms of Indigestion?

The symptoms of indigestion include:

  • Bloating (full feeling)
  • Belching and gas
  • Nausea and vomiting
  • Acidic taste
  • Growling stomach
  • Burning in the stomach or upper abdomen
  • Abdominal pain

These symptoms may increase in times of stress.

People often have heartburn (a burning sensation deep in the chest) along with indigestion. But heartburn is caused by stomach acids rising into the esophagus.

Who Is at Risk for Indigestion?

People of all ages and of both sexes are affected by indigestion. It's extremely common. An individual's risk increases with excess alcohol consumption, use of drugs that may irritate the stomach (such as aspirin), other conditions where there is an abnormality in the digestive tract such as an ulcer and emotional problems such as anxiety or depression.

What Causes Indigestion?

Indigestion has many causes, including:


  • Ulcers
  • GERD
  • Stomach cancer (rare)
  • Gastroparesis (a condition where the stomach doesn't empty properly; this often occurs in diabetics)
  • Stomach infections
  • Irritable bowel syndrome
  • Chronic pancreatitis
  • Thyroid disease


  • Aspirin and many other painkillers
  • Estrogen and oral contraceptives
  • Steroid medications
  • Certain antibiotics
  • Thyroid medicines


  • Eating too much, eating too fast, eating high-fat foods, or eating during stressful situations
  • Drinking too much alcohol
  • Cigarette smoking
  • Stress and fatigue

Swallowing excessive air when eating may increase the symptoms of belching and bloating, which are often associated with indigestion.

Sometimes people have persistent indigestion that is not related to any of these factors. This type of indigestion is called functional, or non-ulcer dyspepsia.

During the middle and later parts of pregnancy, many women have indigestion. This is believed to be caused by a number of pregnancy-related factors including hormones, which relax the muscles of the digestive tract, and the pressure of the growing uterus on the stomach.

How Is Indigestion Diagnosed?

If you are experiencing symptoms of indigestion, make an appointment to see your doctor to rule out a more serious condition. Because indigestion is such a broad term, it is helpful to provide your doctor with a precise description of the discomfort you are experiencing. In describing your indigestion symptoms, try to define where in the abdomen the discomfort usually occurs. Simply reporting pain in the stomach is not detailed enough for your doctor to help identify and treat your problem.

First, your doctor must rule out any underlying conditions. Your doctor may perform several blood tests and you may have X-rays of the stomach or small intestine. Your doctor may also use an instrument to look closely at the inside of the stomach, a procedure called an upper endoscopy. An endoscope, a flexible tube that contains a light and a camera to produce images from inside the body, is used in this procedure.

What Is the Treatment for Indigestion?

Because indigestion is a symptom rather than a disease, treatment usually depends upon the underlying condition causing the indigestion.

Often, episodes of indigestion go away within hours without medical attention. However, if your indigestion symptoms become worse, you should consult a doctor. Here are some helpful tips to alleviate indigestion:

  • Try not to chew with your mouth open, talk while chewing, or eat too fast. This causes you to swallow too much air, which can aggravate indigestion.
  • Drink fluids after rather than during meals.
  • Avoid late-night eating.
  • Try to relax after meals.
  • Avoid spicy foods.
  • Stop smoking.
  • Avoid alcoholic beverages.

If indigestion is not relieved after making these changes, your doctor may prescribe medications to alleviate your symptoms.

How Can I Prevent Indigestion?

The best way to prevent indigestion is to avoid the foods and situations that seem to cause indigestion. Keeping a food diary is helpful in identifying foods that cause indigestion. Here are some other suggestions:

  • Eat small meals so the stomach does not have to work as hard or as long.
  • Eat slowly.
  • Avoid foods that contain high amounts of acids, such as citrus fruits and tomatoes.
  • Reduce or avoid foods and beverages that contain caffeine.
  • If stress is a trigger for your indigestion, re-evaluating your lifestyle may help to reduce stress. Learn new methods for managing stress, such as relaxation and biofeedback techniques.
  • Smokers should consider quitting smoking, or at least not smoking right before or after eating, as smoking can irritate the stomach lining.
  • Cut back on alcohol consumption because alcohol can irritate the stomach lining.
  • Avoid wearing tight-fitting garments because they tend to compress the stomach, which can cause its contents to enter the esophagus.
  • Do not exercise with a full stomach. Rather, exercise before a meal or at least one hour after eating a meal.
  • Do not lie down right after eating.
  • Wait at least three hours after your last meal of the day before going to bed.
  • Raise the head of your bed so that your head and chest are higher than your feet. You can do this by placing 6-inch blocks under the bedposts at the head of the bed. Don't use piles of pillows to achieve the same goal. You will only put your head at an angle that can increase pressure on your stomach and make heartburn worse.

When Should I Call the Doctor About Indigestion?

Because indigestion can be a sign of a more serious health problem, call your doctor if you have any of the following symptoms:

  • Vomiting or blood in vomit (the vomit may look like coffee grounds).
  • Weight loss.
  • Loss of appetite.
  • Black, tarry stools or visible blood in stools.
  • Severe pain in upper right abdomen.
  • Pain in upper or lower right abdomen.
  • Discomfort unrelated to eating.

Symptoms similar to indigestion may be caused by heart attacks. If indigestion is unusual, accompanied by shortness of breath, sweating, or pain radiating to the jaw, neck or arm, seek medical attention immediately.