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Proton-Pump Inhibitors : Proton-pump inhibitors reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid. The reduction of acid prevents ulcers and allows any ulcers that exist in the esophagus, stomach and duodenum to heal. PPIs are used for the prevention and treatment of acid-related conditions such as ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome. They also are used in combination with antibiotics for eradicating Helicobacter pylori, a bacterium that together with acid causes ulcers of the stomach and duodenum. Gastroesophageal Reflux Disease (GERD, Acid Reflux) : Gastroesophageal reflux disease, commonly referred to as GERD, or acid reflux, is a condition in which the liquid content of the stomach regurgitates (backs up, or refluxes) into the esophagus. The liquid can inflame and damage the lining of the esophagus although this occurs in a minority of patients. The regurgitated liquid usually contains acid and pepsin that are produced by the stomach. (Pepsin is an enzyme that begins the digestion of proteins in the stomach.) The refluxed liquid also may contain bile that has backed-up into the stomach from the duodenum. (The duodenum is the first part of the small intestine that attaches to the stomach.) Acid is believed to be the most injurious component of the refluxed liquid. Pepsin and bile also may injure the esophagus, but their role in the production of esophageal inflammation and damage (esophagitis) is not as clear as the role of acid. GERD is a chronic condition. Once it begins, it usually is life-long. If there is injury to the lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the esophagus has healed with treatment and treatment is stopped, the injury will return in most patients within a few months. Once treatment for GERD is begun, therefore, it usually will need to be continued indefinitely. Actually, the reflux of the stomach's liquid contents into the esophagus occurs in most normal individuals. In fact, one study found that reflux occurs as frequently in normal individuals as in patients with GERD. In patients with GERD, however, the refluxed liquid contains acid more often, and the acid remains in the esophagus longer. The cause of GERD is complex. There probably are multiple causes, and different causes may be operative in different individuals or even in the same individual at various times. A small number of patients with GERD produce abnormally large amounts of acid, but this is uncommon and not a contributing factor in the vast majority of patients. The factors that contribute to causing GERD are the lower esophageal sphincter, hiatal hernias, esophageal contractions, and emptying of the stomach. Complications of GERD : Ulcers - The liquid from the stomach that refluxes into the esophagus damages the cells lining the esophagus. The body responds in the way that it usually responds to damage, which is with inflammation (esophagitis). The purpose of inflammation is to neutralize the damaging agent and begin the process of healing. If the damage goes deeply into the esophagus, an ulcer forms. An ulcer is simply a break in the lining of the esophagus that occurs in an area of inflammation. Ulcers and the additional inflammation they provoke may erode into the esophageal blood vessels and give rise to bleeding into the esophagus. Occasionally, the bleeding is severe and may require transfusions of blood and endoscopic (a procedure in which a tube is inserted through the mouth into the esophagus) or surgical treatment. Strictures - Ulcers of the esophagus heal with the formation of scars (fibrosis). Over time, the scar tissue shrinks and narrows the lumen (inner cavity) of the esophagus. This scarred narrowing is called a stricture. Once the narrowing becomes severe enough (usually when it restricts the esophageal lumen to a diameter of one centimeter), swallowed food may get stuck in the esophagus. This situation may necessitate endoscopic removal of the stuck food. Then, to prevent food from sticking, the narrowing must be stretched (widened). Moreover, to prevent a recurrence of the stricture, the reflux also must be prevented. Barrett's esophagus - Long-standing and/or severe GERD causes changes in the cells that line the esophagus. These cells then become pre-cancerous, and finally cancerous. This condition is referred to as Barrett's esophagus, which occurs in approximately 10% of patients with GERD. The type of esophageal cancer associated with Barrett's esophagus (adenocarcinoma) is increasing in frequency. Barrett's esophagus can be recognized visually at the time of an endoscopy and confirmed by microscopic examination of biopsies of the lining cells. Then, patients with Barrett's esophagus may require periodic surveillance endoscopies with biopsies. The purpose of the surveillance is to detect pre-cancerous changes so that cancer-preventing treatment can be started. It is also believed that patients with Barrett's esophagus should receive maximum treatment for GERD to prevent further damage to the esophagus. It is not clear why some patients with GERD develop Barrett's esophagus, but most do not. Cough and asthma -- Many nerves are in the lower esophagus. Some of these nerves are stimulated by the refluxed acid, and this stimulation results in pain (usually heartburn). Other nerves that are stimulated do not produce pain. Instead, they stimulate yet other nerves that provoke coughing. In this way, refluxed liquid can cause coughing without ever reaching the throat! In a similar manner, reflux into the lower esophagus can stimulate esophageal nerves that connect to and can stimulate nerves going to the lungs. These nerves to the lungs then can cause the smaller breathing tubes to narrow, resulting in an attack of asthma. So, GERD is a common cause of unexplained coughing. Although GERD also may be a cause of asthma, it is more likely that it precipitates asthmatic attacks in patients who already have asthma. Although chronic cough and asthma are common ailments, it is not clear just how often they are aggravated or caused by GERD. Inflammation of the throat and larynx -- If refluxed liquid gets past the upper esophageal sphincter, it can enter the throat (pharynx) and even the voice box (larynx). The resulting inflammation can lead to a sore throat and hoarseness. As with coughing and asthma, it is not clear just how commonly GERD is responsible for otherwise unexplained inflammation of the throat and larynx. Inflammation and infection of the lungs -- Refluxed liquid that passes the larynx can enter the lungs. The reflux of liquid into the lungs (called aspiration) often results in coughing and choking. Aspiration, however, can also occur without producing these symptoms. With or without these symptoms, aspiration may lead to infection of the lungs and result in pneumonia. This type of pneumonia is a serious problem requiring immediate treatment. When aspiration is unaccompanied by symptoms, it can result in a slow, progressive scarring (fibrosis) of the lungs that can be seen on chest x-rays. Aspiration is more likely to occur at night because that is when the processes (mechanisms) that protect against reflux are not active and the coughing reflex that protects the lungs also is not active. Peptic Ulcer Disease : A peptic ulcer is a hole in the gut lining of the stomach, duodenum, or esophagus. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer. An ulcer occurs when the lining of these organs is corroded by the acidic digestive juices which are secreted by the stomach cells. Peptic ulcer disease is common, affecting millions of Americans yearly. For many years, excess acid was believed to be the major cause of ulcer disease. Accordingly, treatment emphasis was on neutralizing and inhibiting the secretion of stomach acid. While acid is still considered significant in ulcer formation, the leading cause of ulcer disease is currently believed to be infection of the stomach by a bacteria called "Helicobacter pyloridus" (H. pylori). Another major cause of ulcers is the chronic use of anti-inflammatory medications, commonly referred to as NSAIDs (nonsteroidal anti-inflammatory drugs), including aspirin. Cigarette smoking is also an important cause of ulcer formation and ulcer treatment failure. H. pylori bacteria is very common, infecting more than a billion people worldwide. It is estimated that half of the United States population older than age 60 has been infected with H. pylori. Infection usually persists for many years, leading to ulcer disease in 10 % to 15% of those infected. H. pylori is found in more than 80% of patients with gastric and duodenal ulcers. While the mechanism of how H. pylori causes ulcers is not well understood, elimination of this bacteria by antibiotics has clearly been shown to heal ulcers and prevent ulcer recurrence. Cigarette smoking not only causes ulcer formation, but also increases the risk of ulcer complications such as ulcer bleeding, stomach obstruction and perforation. Cigarette smoking is also a leading cause of ulcer medication treatment failure. Contrary to popular belief, alcohol, coffee, colas, spicy foods, and caffeine have no proven role in ulcer formation. Similarly, there is no conclusive evidence to suggest that life stresses or personality types contribute to ulcer disease. Symptoms of ulcer disease are variable. Many ulcer patients experience minimal indigestion or no discomfort at all. Some report upper abdominal burning or hunger pain one to three hours after meals and in the middle of the night. These pain symptoms are often promptly relieved by food or antacids. The pain of ulcer disease correlates poorly with the presence or severity of active ulceration. Some patients have persistent pain even after an ulcer is completely healed by medication. Others experience no pain at all, even though ulcers return. Ulcers often come and go spontaneously without the individual ever knowing, unless a serious complication (like bleeding or perforation) occurs. |
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12th March 2010
