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.

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.

Peptic Ulcer Treatment & Medication : The goal of ulcer treatment is to relieve pain and to prevent ulcer complications, such as bleeding, obstruction, and perforation. The first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The next step is medications. Antacids neutralize existing acid in the stomach. Antacids such as Maalox, Mylanta, and Amphojel are safe and effective treatments. However, the neutralizing action of these agents is short-lived, and frequent dosages are required. Magnesium containing antacids, such as Maalox and Mylanta, can cause diarrhea, while aluminum agents like Amphojel can cause constipation. Ulcers frequently return when antacids are discontinued. Studies have shown that a protein in the stomach called histamine stimulates gastric acid secretion. Histamine antagonists (H2 blockers) are drugs designed to block the action of histamine on gastric cells, hence reducing acid output. Examples of H2 blockers are cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). While H2 blockers are effective in ulcer healing, they have limited role in eradicating H. pylori without antibiotics. Therefore, ulcers frequently return when H2 blockers are stopped. Generally, these drugs are well tolerated and have few side effects even with long term use. In rare instances, patients report headache, confusion, lethargy, or hallucinations. Chronic use of cimetidine may rarely cause impotence or breast swelling. Both cimetidine and ranitidine can interfere with body's ability to handle alcohol. Patients on these drugs who drink alcohol may have elevated blood alcohol levels. These drugs may also interfere with the liver's handling of other medications like Dilantin, Coumadin, and theophylline. Frequent monitoring and adjustments of the dosages of these medications may be needed. Omeprazole (Prilosec) is more potent than H2 blockers in suppressing acid secretion. Prilosec virtually shuts down stomach acid output. While Prilosec is comparable to H2 blockers in effectiveness in treating gastric and duodenal ulcers, it is superior to H2 blockers in treating esophageal ulcers. Esophageal ulcers are more sensitive than gastric and duodenal ulcers to minute amounts of acid. Therefore, complete acid suppression, which is accomplished by Prilosec, is important for esophageal ulcer healing. Interestingly, the complete shut down of stomach acid does not have any effect on the patient's ability to digest and absorb nutrients. Prilosec is well tolerated. In large doses, Prilosec can cause small bowel tumors in rats. No such tumors have been reported thus far in humans, even with long term use. Safe duration of long-term treatment with Prilosec has not been firmly established. Many people harbor H. pylori in their stomachs without ever having pain or ulcers. It is not completely clear whether these patients should be treated with antibiotics. More studies are needed to answer this question. Patients with documented ulcer disease and H. pylori infection should be treated with antibiotic combinations. H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with Prilosec, H2 blockers or Pepto-Bismol. Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl), and clarithromycin (Biaxin). Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options). Elimination of this bacteria may also decrease the risk of developing gastric cancer in the future. Treatment with antibiotics carries the risk of allergic reactions, diarrhea, and sometimes severe antibiotic-induced colitis (inflammation of the colon). There is no conclusive evidence that dietary restrictions and bland diets play a role in ulcer healing. No proven relationship exists between peptic ulcer disease and the intake of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and alcohol can cause gastritis, moderation in alcohol and coffee consumption is often recommended.

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.