When we eat, food is carried from the mouth through the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in adults. At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle that relaxes and opens when food reaches that point, called the lower esophageal sphincter (LES). This allows food to enter the stomach and then closes to prevent the back-up of food and acid into the esophagus. Reflux can occur if the LES is weak or stays relaxed too long.

By Gabe Mirkin MD, April 11, 2011  —  If you suffer from belching and burning in your stomach, your doctor will often recommend that you have a tube placed down your throat and into your stomach to check for cancer and stomach ulcers. Sometimes, the doctor finds Barrett’ esophagus, stomach tissue in your esophagus which can become cancerous. There is no established treatment for Barrett’s esophagus. Food passes down a narrow tube called the esophagus and into a wider area called the stomach. The tissue covering the inner lining of the stomach is different from that lining the esophagus.

If your doctor finds stomach-lining cells in your esophagus, he diagnoses Barrett’s esophagus, which can turn to cancer. However, this happens so seldom that rather than cutting out your esophagus, most doctors recommend checking you yearly to see if the cells become cancerous. We know that most people with stomach ulcers are infected with a family of bacteria called helicobacter. However, most of the people who have Barrett’s esophagus do not have helicobacter. Those who have both helicobacter and Barrett’s esophagus all have severe redness, swelling and irritation (1). So all people with helicobacter and Barrett’s esophagus should be treated with the standard two antibiotics and one ulcer medicine that are used to cure helicobacter in people with stomach irritation.

A study from Japan showed that men who are treated with antibiotics for Helicobacter pylori, the germ that causes stomach ulcers, are not at increased risk for Barrett’s esophagus (3). This study confirms more than a thousand other studies showing that helicobacter can cause stomach ulcers, and it also shows that three years later, cured patients are asymptomatic and do not suffer an increased incidence of Barrett’s esophagus.

References:

  • RDJ Henihan, RC Stuart, N Nolan, TF Gorey, TPJ Hennessy, CA Omorain. Barrett’s esophagus and the presence of Helicobacter pylori. American Journal of Gastroenterology 93: 4 (APR 1998):542-546.
  • RM Navaratnam, MC Winslet. Barrett’s oesophagus. Postgraduate Medical Journal 74: 877 (NOV 1998):653-657.
  • Improvement of reflux symptoms 3 years after cure of Helicobacter pylori infection: A case-controlled study in the Japanese population. Helicobacter, 2002, Vol 7, Iss 4, pp 219-224. H Miwa, Y Sugiyama, T Ohkusa, A Kurosawa, M Hojo, T Yokoyama, T Hamada, H Basyuda, N Sato. Sato N, Juntendo Univ, Sch Med, Dept Gastroenterol, Tokyo 113, JAPAN

 

 

 

Helicobacter and Stomach Ulcers

 

 

By Gabe Mirkin MD, April 11, 2011  —  If you belch or have burning in your stomach or chest, particularly when your stomach is empty, you have either an infection, a tumor, or an incurable condition called Gastroesophageal reflux disease (GERD). Infection with bacteria such as helicobacter pylori is by far the most common cause.

I recommend that you get an upper GI series X ray to rule out a tumor. That almost always comes back negative to tell you that you do not have tumor. Then you get a blood test for Helicobacter Pylori and you should be treated with antibiotics, even if the blood test is negative, because there are at least 23 other species of bacteria that this test does not detect. Your gastroenterologist will want to put a tube down your mouth and into your stomach, but the biopsy that he will do to find the helicobacter can often miss the germ even when it is there (11). If your doctor does not offer the antibiotic treatment (see below), you will be stuck with a diagnosis of regurgitation, called GERD, which means you have pain and no one can tell you why. You will need to take medication for the rest of your life.

An article in the medical journal GUT reported that at least 24 different bacteria have been shown to cause stomach ulcers (16). Since doctors do not have any way to check for all 24 different bacteria (10), all people with belching and burning in the stomach should be given a one-week course of antibiotics that are used to treat the most common cause of stomach ulcers, called Helicobacter Pylori.

Twenty years ago, stomach ulcers were treated by drinking cream. Today, almost everyone with belching and burning in the stomach should be treated with antibiotics. In 1983 they laughed at Dr. Barry Marshall when he reported that stomach ulcers were caused by infection with helicobacter pylori and could be cured with antibiotics. Fellow physicians were so mean to him that he responded by swallowing a vial of helicobacter and almost died. He recently received the Nobel Prize for his pioneering work.

 

 

 

 

Now almost every reasonable physician agrees that all people who have belching and burning in the stomach and a positive blood test for helicobacter pylori can be cured with antibiotics, but many gastroenterologists stubbornly refuse to treat patients with ulcer symptoms and a negative blood test or biopsy for that germ. They are clearly wrong because literature shows that at least 24 germs cause an irritation in the stomach (9), including H. helmannii (13), H. felis, H. rappini, H. cinaedi, H sp. Strain Mainz (14) H. fennelliae and H. pullorum, H. hepaticus, H. Billis, H. canis, H. Hills (15), cytomegalovirus and mycoplasma (1,2,3,4,5,6,7,), and Helicobacter mesocricetorum sp nov (12).

Helicobacter species have been isolated from the stomachs of dogs, cats, ferrets, pigs, monkeys and cheetahs, birds, mice, chickens. The standard treatment of one week of clarithromycin 500 mg twice a day, metronidazole 500 mg twice a day and omeperazole 20 mg once a day is safe and effective. These germs also grow in saliva, so they can be transmitted between family members and pets. So some doctors prescribe antibiotics to all people with belching and stomach burning, and check the other members of the household for symptoms.

At least 12 weeks later, you need a follow up blood test for helicobacter. If your symptoms are gone and the titre drops, you are probably cured. If your helicobacter titre is still high, your helicobacter is probably resistant to metronidazole and you need to be treated for at least ten days with amoxacillin 500 mg four times a day, tetracycline 500 mg three times a day and omeperazole 20 mg once a day (1). If you still have symptoms, you may need to have a tube put down your throat by a gastroenterologist. If you have regurgitation of stomach acid into your esophagus (reflux, hiatal hernia), you may need to be treated with 20 mg omeperazole once a day. Some people who are not infected with helicobacter may benefit from taking clarithromycin or other antibiotic for a longer period of time.

Helicobacter may also cause liver disease, blood vessel diseases such as clotting and heart attacks, and certain skin conditions such as rosacea.

 

 

What are Symptoms of an Ulcer?

 

MedicineNet.com, April 11, 2011  —  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.

 

 

How is an Ulcer Diagnosed?

 

The diagnosis of an ulcer is made by either a barium upper GI x-ray or an upper endoscopy (EGD-esophagogastroduodenoscopy) The barium upper GI x-ray is easy to perform and involves no risk or discomfort. Barium is a chalky substance administered orally. Barium is visible on x- ray, and outlines the stomach on x-ray film. However, barium x-rays are less accurate and may not detect ulcers up to 20% of the time.

An upper endoscopy is more accurate, but involves sedation of the patient and the insertion of a flexible tube through the mouth to inspect the stomach, esophagus, and duodenum. Upper endoscopy has the added advantage of having the capability of removing small tissue samples (biopsies) to test for H. pylori infection. Biopsies can also be examined under a microscope to exclude cancer. While virtually all duodenal ulcers are benign, gastric ulcers can occasionally be cancerous. Therefore, biopsies are often performed on gastric ulcers to exclude cancer.

 

 

What treatments are available for peptic ulcers?

 

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.

Proton-pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium), and rabeprazole (Aciphex) are more potent than H2 blockers in suppressing acid secretion. Different proton-pump inhibitors are very similar in action and there is no evidence that one is more effective than another in healing ulcers. While proton-pump inhibitors are 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, more complete acid suppression accomplished by proton-pump inhibitors are important for esophageal ulcer healing. Proton-pump inhibitors are well tolerated. Side effects are uncommon; they include headache, diarrhea, constipation, nausea and rash. Interestingly, proton-pump inhibitors do not have any effect on a person’s ability to digest and absorb nutrients. Proton-pump inhibitors have also been found to be safe when used long term, without serious adverse health effects reported.

Sucralfate (Carafate) and misoprostol (Cytotec) are agents that strengthen the gut lining against attacks by acid digestive juices. Carafate coats the ulcer surface and promotes healing. The medication has very few side effects. The most common side effect is constipation and the interference with the absorption of other medications. Cytotec is a prostaglandin-like substance commonly used to counteract the ulcer effects of NSAIDs. Studies suggest that Cytotec may protect the stomach from ulceration in those who take NSAIDs on a chronic basis. Diarrhea is a common side effect. Cytotec can cause miscarriages when given to pregnant women, and should be avoided by women of childbearing age.

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 a proton-pump inhibitor, H2 blockers or Pepto-Bismol. Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl), clarithromycin (Biaxin), and levofloxacin (Levaquin). 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.

Summary

With modern treatment, patients with ulcer disease can lead normal lives without lifestyle changes or dietary restrictions. Cigarette smokers have been found to have higher ulcer complications and treatment failure. Eradication of the bacteria H. pylori not only heals ulcers, but also prevents the recurrence of ulcer disease.

Peptic Ulcer Disease At A Glance

  • Peptic ulcers can affect the stomach, duodenum, or esophagus.
  • Peptic ulcer formation is related to H. pylori bacteria in the stomach, anti-inflammatory medications, and smoking cigarettes.
  • Ulcer pain may not correlate with the presence or severity of ulceration.
  • Diagnosis of ulcer is made with barium x-ray or endoscopy.
  • Complications of ulcers include bleeding, perforation, and blockage of the stomach (gastric obstruction).
  • Treatment of ulcers involves antibiotic combinations to eradicate H. pylori, eliminating risk factors, stomach acid suppression with medications, and preventing complications.

 

What Are Cataracts?

A cataract is a progressive, painless clouding of the lens of the eye. Cataracts occur when protein builds up on the lenses and blocks some of the light from passing through, making it difficult to see clearly. Over time, cataracts can cause blindness. They’re often related to growing older, but sometimes they can develop in younger people.

 

 

How Cataracts Affect Your Vision

In a normal eye, light enters and passes through the lens. The lens focuses that light into a sharp image on the retina, which relays messages through the optic nerve to the brain. If the lens is cloudy from a cataract, the image you see will be blurry. Other eye conditions, such as myopia, cause blurry vision, too, but cataracts produce some distinctive signs and symptoms.

 

 

Cataract Symptom: Blurry Vision

Blurry vision at any distance is the most common symptom of cataracts. Your view may look foggy, filmy, or cloudy. Over time, as the lenses become more clouded, less light reaches the retina. People with cataracts may have an especially hard time seeing at night.

 

Cataract Symptom: Glare

Another early symptom of cataracts is glare, or sensitivity to light. You may have trouble seeing in bright sunlight. Indoor lights that once didn’t bother you now may seem too bright or have halos. Driving at night may become a problem because of the glare caused by oncoming headlights.

 

Cataract Symptom: Double Vision

Sometimes, cataracts can cause double vision (also known as diplopia). As the cataract grows larger, the double vision may go away.

 

Cataract Symptom: Color Changes

Cataracts can affect your color vision, making some hues look faded. Your vision may gradually take on a brownish or yellowish tinge. At first, you may not notice this discoloration. But over time, it may make it harder to distinguish blues and purples.

 

Cataract Symptom: Second Sight

Sometimes, a cataract may temporarily improve a person’s ability to see close-up, because the cataract acts as a stronger lens. This phenomenon is called second sight, because people who may have once needed reading glasses find that they don’t need them anymore. As the cataract worsens however, this goes away and vision worsens again.

 

 

Cataract Symptom: New Prescription

Frequent changes to your eyeglass or contact lens prescription can be a sign of cataracts. This is because cataracts are progressive, meaning they get worse over time.

 

 

Who Gets Cataracts?

The majority of cataracts are related to aging. More than half of Americans over 65 have cataracts. Babies are sometimes born with cataracts, also called congenital cataracts, or children may develop them as a result of injury or illness.

 

What Causes Cataracts?

The exact cause of cataracts is unknown. While the risk grows as you get older, these factors may also contribute:

 

How Are Cataracts Diagnosed?

Most cataracts can be diagnosed with an eye exam. Your eye doctor will test your vision and examine your eyes with a slit lamp exam to look for problems with the lens and other parts of the eye. The pupils are dilated to better examine the back of the eye, where the retina and optic nerve lie.

 

 

Surgery for Cataracts

If your vision loss can’t be corrected with glasses or contact lenses, you may need surgery to remove the cataracts. In cataract surgery, the cloudy lens is removed and replaced with an artificial lens. The surgery, which is done on an outpatient basis, is safe and extremely effective at improving vision. If cataracts are present in both eyes, surgery will be done on one eye at a time.

 

Types of Cataract Surgery

There are two types of cataract surgery. In the more common type, called phacoemulsification, or phaco, the doctor makes a tiny incision in the eye and breaks up the lens using ultrasound waves. The lens is removed, and an artificial lens (called an intraocular lens, or IOL) is put in its place. In extracapsular cataract surgery, the doctor makes a larger incision and removes the cloudy part of the lens in one piece.

 

Cataract Surgery Innovations

One recent development in cataract surgery is the multifocal IOL, which can correct both near and distance vision. Conventional “monofocal” lenses only correct for distance vision, meaning reading glasses are still needed after surgery. Other “premium” implants are available to correct presbyopia, myopia, and astigmatism. A lens for better color vision is in development (shown here next to a dime.) An experimental laser cataract surgery is also showing promise, giving more accurate results with a less invasive procedure.

 

What to Expect After Surgery

For a few days, your eye may be itchy and sensitive to light. You may be prescribed drops to aid healing and asked to wear an eye shield or glasses for protection. It’ll take about eight weeks for your eye to heal completely, though your vision should begin to improve soon after surgery. You may still need glasses, at least occasionally, for distance or reading — as well as a new prescription after healing is complete.

 

Cataract Surgery Risks

Complications from cataract surgery are rare. The most common risks are bleeding, infection, and changes in eye pressure, which are all treatable when caught early. Surgery slightly raises the risk of retinal detachment, which requires emergency treatment. Sometimes, the tissue around the IOL can become cloudy, even years after surgery. This “after-cataract” is corrected by using a laser to make a tiny hole in the capsule to allow light to pass through.

 

Should You Have Cataract Surgery?

Whether or not to have cataract surgery is up to you and your doctor. Occasionally cataracts need to be removed right away, but this isn’t usually the case. Cataracts affect vision slowly over time, so many people wait to have surgery until glasses or contacts no longer improve their vision enough. If you don’t feel that your cataracts are causing problems in your day-to-day life, you may choose to wait.

 

 

 

Surgery for Cataracts

If your vision loss can’t be corrected with glasses or contact lenses, you may need surgery to remove the cataracts. In cataract surgery, the cloudy lens is removed and replaced with an artificial lens. The surgery, which is done on an outpatient basis, is safe and extremely effective at improving vision. If cataracts are present in both eyes, surgery will be done on one eye at a time.

 

Types of Cataract Surgery

There are two types of cataract surgery. In the more common type, called phacoemulsification, or phaco, the doctor makes a tiny incision in the eye and breaks up the lens using ultrasound waves. The lens is removed, and an artificial lens (called an intraocular lens, or IOL) is put in its place. In extracapsular cataract surgery, the doctor makes a larger incision and removes the cloudy part of the lens in one piece.

 

 

Cataract Surgery Innovations

One recent development in cataract surgery is the multifocal IOL, which can correct both near and distance vision. Conventional “monofocal” lenses only correct for distance vision, meaning reading glasses are still needed after surgery. Other “premium” implants are available to correct presbyopia, myopia, and astigmatism. A lens for better color vision is in development (shown here next to a dime.) An experimental laser cataract surgery is also showing promise,

 

Tips to Prevent Cataracts

Things you can do to lower your risk of developing cataracts:

  • Don’t smoke.
  • Always wear a hat or sunglasses in the sun.
  • Keep diabetes well controlled.
  • Limit alcohol consumption.

 

 

By Gabe Mirkin MD, April 11, 2011  —  A study from Colorado State University showed that oats lower the small, dense LDL cholesterol more effectively than wheat.

Both oats and wheat contain fiber, but wheat contains more insoluble fiber that primarily helps prevent constipation, while oats contain more of the soluble fiber that helps lower cholesterol. In your bloodstream, cholesterol is packaged into a good HDL cholesterol and a bad LDL cholesterol, that is further classified into an LDL subunit called small, dense LDL cholesterol. This is the LDL cholesterol fraction associated with a high susceptibility to getting a heart attack.

Soluble fiber found in oats specifically helps to lower blood levels of the bad small, dense LDL cholesterol that increases risk for heart attacks. While oats are a particularly good source of soluble fiber, other whole grains also contain some soluble fiber as do fruits, vegetables, beans and other seeds. Many products made with oats and other grains have some or most of the fiber removed, so this study applies only to whole grains and products made from whole grains.

High-fiber oat cereal compared with wheat cereal consumption favorably alters LDL-cholesterol subclass and particle numbers in middle-aged and older men.

Reference:

American Journal of Clinical Nutrition, 2002, Vol 76, Iss 2, pp 351-358. BM Davy, KP Davy, RC Ho, SD Beske, LR Davrath, CL Melby. Melby CL, Colorado State Univ, Dept Food Sci & Human Nutr, Ft Collins,CO 80523 USA