Acid reflux and heartburn are two terms familiar to at least a fourth of the U.S. population, but a broader term was needed to accurately describe this health problem. The NIH classifies these problems under the title Gastroesophageal Reflux Disease (GERD) and Related Esophageal Disorders, and states that statistics in 1990 showed that 20 percent of the U.S. population suffered reflux symptoms at least weekly, with 1,707 yearly deaths attributed in 2002. In the last decade it is estimated that GERD rates in the population may have increased 50 percent, with estimates in 2014 showing that as many as 27.8 percent of the U.S. population could be diagnosed with GERD, while incidence in other countries is much lower. It is obvious that the current standard medical protocol to address GERD and related esophageal disorders is totally inadequate, and may be doing more harm than good for many patients. Unwarranted and inappropriate prescription of gastric acid inhibiting drugs such as Proton Pump Inhibitors (PPIs) without integration of restorative medicine has led to chronic addiction and rebound withdrawal with these drugs, and a host of serious adverse health effects with long-term use that is still taken too lightly, despite strong FDA warnings. Restoration of gastric function to allow for drug withdrawal is not a simple process, and a persistent course of therapy with Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM) may be needed, with short courses of frequent acupuncture stimulation and a persistent step-by-step approach with herbal and nutrient medicine and an individualized diet and lifestyle habit assessment. Of course, the best course of therapy would be to prevent these problems with GI dysfunction, or to seek treatment at an early stage and utilize safe and effective Complementary therapies, not a quick prescription or now even a non-prescription off-the-shelf course of chronic dependency on gastric acid inhibiting drugs such as Proton Pump Inhibitors.
GERD is a more serious form of gastroesophageal reflux, which occurs when the lower esophageal sphinctre opens spontaneously or does not close properly, allowing stomach contents, which are irritating to the esophageal tissues, to rise up out of the stomach. Because these stomach acids can dissolve normal tissue, health of the esophageal sphincter and esophagus are damaged and scarred, and in some cases esophageal cancer may occur. Frequently, hiatal hernias are also seen in these disorders when endoscopy is performed. Hiatal hernia is a condition in which a portion of the stomach protrudes through a hernial tear in the diaphragm upward and into the chest cavity. But treating stomach complaints without sufficient analysis has led to misdiagnosis and wrong treatment in a high percentage of patients with GERD symptoms. Overprescription of gastric acid suppressing drugs has led to an enormous health problem as well, with spinal and pelvic osteoporosis and microfractures, infection and chronic Irritable Bowel Syndrome due to overgrowths of such microbial pathogens as Clostridium difficile, pernicious anemias and neurological diseases caused by Vitamin B12 deficiency, and a host of health problems attributed to deficiencies of other essential minerals, such as magnesium, as well as a dramatically increased risk over time for chronic kidney disease.
“High levels of stomach acid are blamed for nearly every midsection complaint. Yet, low stomach acid, or hypochlorydia is far more likely to be the problem (especially with aging). Symptoms of low hydrochloric acid are similar to those of excess HCL and are frequently mistaken for excess acid." Carolyn Pierini, CLS (ASCP), CNC. Restoration of gastric function is an essential therapy to prevent or resolve a host of chronic diseases, and a mistaken reliance on acid-inhibiting drugs, rather than restoration of gastric homeostasis, has resulted in increased incidence of a wide variety of chronic diseases associated with GERD.
Acid reflux and heartburn are not the only common symptoms of GERD. The U.S. NIH (National Institutes of Health) states that trouble swallowing, dry cough and asthmatic symptoms may also signify GERD, even in the absence of heartburn and reflux symptoms. Chronic GERD is highly associated with tissue changes in the esophagus and upper airway, such as Barrett's Esophagus, allergic asthma and COPD (chronic obstructive pulmonary disease), as well as Idiopathic Pulmonary Fibrosis and an alarming increase in adult Eosinophilic Esophagitis, and disease of immune dysfunction. A 2009 report printed in the Annals of Thoracic Medicine (see link below in Additional Information) reported that GERD “may cause, trigger or exacerbate many pulmonary diseases", and that noncardiac chest pain, referred abdominal pain, recurrent cough and wheeze, and even post-nasal drip and throat irritation may result. While the exact pathological causes of GERD are still unclear, experts note that a host of contributing factors are known, signifying a multifactorial problem. Factors that affect the health of the lower esophageal sphincter include the use of medications such as antihistamines, calcium channel blockers (high blood pressure), nitrates (cardiac disease and angina), and theophyllines (COPD and asthma, e.g Uniphyl), excess use of alcohol and/or cigarettes, obesity, poor posture, a diet that includes too many fried or fatty foods, drinks with caffeine, soft drinks, acidic and spicy foods, as well as poor eating habits, such as eating before bedtime, and consuming large meals. Medical conditions associated with GERD include diabetes, hiatal hernia, obesity, rapid weight gain and pregnancy. Obviously, a more thorough diagnostic analysis and expanded treatment protocol is needed, and the stubborn refusal to do this could be considered malpractice. The sales of more than $10 billion worth of these acid inhibiting drugs yearly is obviously being protected at the expense of public health. The solution is not a binary black or white decision, good or bad, but a sensible and nuanced look at a dangerous and prevalent health problem that is increasing yearly in scope, and should be resolved with the integration of restorative medicine.
It is now widely acknowledged that the strategy for resolving GERD has been overly simplistic, relying on the notion that a simple excess of stomach acid production was the problem. Since the production of stomach acids in digestion involves a complex feedback mechanism and cycle of effects, and transient lower esophageal sphincter relaxations are neurally mediated and must occur before the gastroesophageal junction can open, the problem is not a simple matter of overproduction of stomach acids, or even a simple matter that pressure from a full stomach causing reflux dysfunction of the lower esophageal sphincter. In fact, the multifactorial cycle of dysfunctions underlying the pathophysiology of GERD involves deficient production of timely stomach acids in digestion more than the overproduction, although excess response in gastric acids results when poor acid production delays stomach emptying. The underlying problem of stomach dysfunction and hypochloridia, or poor production of stomach acids when needed, is also now considered to be a key contributing factor in Irritable Bowel Disease (IBS) (see the study linking GERD and IBS cited below). As more and more scientific study is devoted to this prevalent health problem, patients and physicians are recognizing that dysfunctional health of the stomach, esophagus and small intestine may play a big role in many other health problems, and the health and homeostatic function of the gastrointestinal system needs to be restored to prevent a wide variety of diseases, and to avoid aggravation of symptoms in a host of diseases.
The too simplistic treatment strategy for GERD and related esophageal disorders, namely the widespread prescription of gastric acid inhibiting drugs, has resulted in major risks and adverse effects related to chronic use of these drugs. In 2006, the U.S. Centers for Disease Control and Prevention identified both GERD and long-term use of acid-inhibiting drugs as highly linked to the explosive rise in Clostridium difficile infection, which is believed to be a leading cause of both acute and chronic diarrheas, and in 2012, the U.S. FDA issued warnings that proton pump inhibitors (the most common type of acid-inhibiting drugs) are linked to a considerable increase in risk, perhaps doubling, of Clostridium difficile infection or overgrowth. In the March, 2012 issue of the Journal of the American Medical Association (JAMA. 2012 Mar 14;307(10):1014), research showed that the extreme rise in gastroenteritis related to Clostridium difficile bacteria was indeed linked to use of gastric reflux drugs.
Since Clostridium difficile is a gram-negative spore-forming anaerobic bacteria that naturally resides in the human intestinal tract (kept in check by a healthy biota), is ubiquitous in the soil and foods we eat, and is now largely antibiotic-resistant due to overuse of antibiotics in both humans and feedlot animals, this presents an alarming problem. In the hospital setting, weakened patients, especially the elderly, are at risk for this common intestinal infection advancing to the sometimes fatal pseudomembranous colitis and toxic megacolon, and public health statistics noted that a doubling of Clostridium difficile hospitalizations occurred from 2001 to 2005, with nearly 1 percent of all U.S. hospitalizations involving serious Clostridium difficile infections in 2009, according to a report by the AHRQ (U.S. Health and Human Services Agency for Healthcare Research and Quality). In 2014, the New York Times reported that well over 14,000 nocosomial (hospital-related) deaths now occur yearly that are attributed to Clostridium difficile enteritis, largely due to antibiotic resistant strains. Since overgrowth of Clostridium difficile also commonly causes chronic mild symptoms of IBS, such as abdominal cramp and tenderness, in the absence of diarrhea, many experts now believe that this and other microbial infections or overgrowths are very prevalent in the population, and the acquiring of a threatening case of Clostridium difficile is related to poor GI health and biotic imbalance. Both the chronic use of medications that block gastric acid secretions and the overuse of antibiotics are now highly associated with a serious overgrowth of this common gut bacteria. While short-term use of gastric inhibiting drugs may be necessary, intelligent patients will seek to correct the underlying cycle of dysfunction and avoid chronic use of these drugs.
How would one know whether chronic use of common gastric acid inhibiting drugs has led to Clostridium difficile infection or other signs of gatrointestinal dysfunction and ill health? This is not easy to answer. For example, while the U.S. CDC (Centers of Disease Control and Prevention) states that Clostridium difficile overgrowth may produce 2 exotoxins, typed A and B, and these account for 15-25 percent of all antibiotic-associated diarrhea episodes presented at hospitals and medical clinics, most patients that test positive for Clostridium difficile and/or the exotoxins A and B do not show clinical symptoms. In the cases where pseudomembranous colitis and toxic megacolon occur, with acute and severe watery diarrhea, nausea, loss of appetite and abdominal tenderness, common stool testing does not even test for Clostridium diffiicile, and a specialized stool testing for C. difficile is the stool test most associated for false-positives due to the presence of nontoxic strains of Clostridium difficile. To clarify, testing for the isolates of toxin production, or toxigenic culture of stool sample, may be performed. This is labor intensive and requires a specialized culture environment, leading to a long test result time, up to 96 hours. PCR (polymerase chain testing of the DNA) may be used, and are highly sensitive, and antigen detection may be used as well, but none of these tests are routinely used when a patient presents with acute colitis. Clostridium difficile exotoxins are very unstable as well, and may degrade at room temperature within 2 hours after detection. False-negatives in testing are common. All of this means that normally health providers do not test for the Clostridium difficile strains and toxins, and so cases of C. difficile are highly underreported. It also means that, while Clostridium difficile infection is now very common, many patients with the infection never know they had it, and since the pathogenic strains of this bacterium are spore-boring, eradication with antibiotics may not prevent the regrowth. We also see that after taking a harsh course of antibiotics, that Clostridium difficile infection is one of the fairly common results, and chronic use of acid-inhibiting proton-pump inhibitors for gastric acid are the chief risk factor.
The history of treatment strategy for GERD has not changed as the scientific study of this disorder clarified the actual pathophysiology of the disease. Long ago, scientific study found that allopathic drugs could block key pathways of stomach acid production, thereby inhibiting excess gastric secretion that could lead to esophageal tissue destruction. Since these early studies, we now know that there are more problems involved in the pathology of gastric reflux and esophageal disease (GERD) than simple excess gastric acid production. Standard medicine has not responded to research as it developed, instead sticking with an outdated treatment protocol because of the enormous profits generated by these drugs produced from the initial scientific studies. For example, in 2009, studies have shown that adenosine is a key inflammatory mediator, and that high extracellular levels of adenosine suppress and resolve chronic inflammation in IBD (inflammatory bowel disease), whereas chronic use of standard medication for GERD, proton pump inhibitors, increases intercellular uptake of adenosine, and decreases extracellular concentration to inhibit gastric acid secretion. In effect, the drugs used to treat one symptom were creating a problem that led to other symptoms and disease, namely the explosive growth in incidence of IBD and IBS (irritable bowel syndrome). The end result of chronic use of these drugs could be poor inflammatory modulation and inflammatory bowel disease, as well as irritable bowel syndrome, which is growing exponentially in incidence in the U.S. population. Prescription patterns did not change with this new information. Instead, more prescriptions of drugs were added to the individual's treatment protocol once health problems arose from the chronic use of the gastric acid inhibiting drugs to treat the health problems created by the gastric acid inhibitors. The common practice of adding more drugs to treat adverse effects of prescription medications (polypharmacy), rather than discontinuing the problematic medication and integrating Complementary Medicine to solve the health problem, creates a growing health problem for many patients, and increases the overall cost of healthcare and the cost of insurance policies and public health spending.
These gastric acid inhibitors are now both routinely prescribed and generic, found on the drugstore shelf, without prescription. Studies by the pharmaceutical manufacturer, Pfizer, reported in 2007 that epidemiological studies identified an association between gastric acid suppressant drugs and Clostridium difficile colitis, as well as community-acquired pneumonia (Int J Infect Dis. 2007 Sep;11(5):417-22). These two problems have now become endemic to our hospitals and clinics, with about 94 percent of cases of C. difficile gastroenteritis occurring in hospitals, clinics and nursing homes where proton pump inhibitors are overprescribed, and the immune health of the patients are weakened. Decreased Vitamin B12 and calcium absorption, anemia and osteoporotic fractures, a 4-fold increased incidence of heart arrhythmias due to changes in pH and potassium absorption, as well as health problems related to decreased magnesium, have all been noted as well, all potential adverse effects of prolonged use of these gastric acid inhibiting drugs, especially in the elderly population. Risk versus benefit, a standard practice of assessment when prescribing drugs, was largely ignored. Short-term use of these gastric acid inhibitors shows a host of less severe symptoms affecting less than 10 percent of patients, but long-term use is showing how inhibition of gastric function leads to a variety of serious health problems. It is time to consider a safe and holistic treatment protocol with Complementary and Integratve Medicine (CIM/TCM) to restore gastric function rather than inhibit it. Even if these drugs are used for a short time to relieve symptoms, Complementary Medicine may be used concurrently to restore gastric function and promote healing of the stomach and esophageal tissues, and reduction of overgrowths of problematic bacteria such as H. pylori.
Standard Treatment of GERD, GER and Dsypepsia presents a host of health problems and has to strong FDA warnings
In recent years, the FDA (U.S. Food and Drug Administration) has issued numerous warnings about the proton-pump inhibiting (PPI) drugs used to treat the now prevalent chronic problem diagnosed as GERD (gastro-esophageal reflux disease). The warnings show that evidence confirms that long-term use and high dosage are associated with anemia, bone loss, increased Clostridium infection in the gut, hospital-acquired pneumonia, and other serious effects of nutritional deficiencies generated by the inhibition of normal gastric function. The FDA has indicated that concurrent use of PPI drugs with a common blood thinner, Plavix, may decrease the effectiveness of Plavix, and expose the patients to cardiovascular risk increase. More recent studies have linked obesity and occurrence of pneumonia with PPIs. A number of experts now recommend that patients use these proton-pump inhibiting drugs for the shortest possible duration, no longer than 12 weeks. This has been problematic, as the use of PPIs to control symptoms is shown to breed dependency. In a June 26, 2012 article in the New York Times Science section, entitled Combating Acid Reflux May Bring a Host of Ills, one expert, Dr. Shoshana J. Herzig of Beth Israel Deaconess Medical Center in Boston, states: “Studies have shown that once you're on them, it's hard to stop taking them. It's almost like an addiction." She explains that when one takes drugs to block the acid production, the body responds by creating more acid producing cells. When you stop taking the drug, the level of acid is excessive. The stomach may have suffered from hypofunction and deficient or delayed production of acids before, with episodes of accumulated acidity and poor stomach emptying. Now, the stomach is hyperfunctional, producing excess acid frequently. Not only these problems, but the lack of prevention of stomach and esophageal cancers, one part of the marketing strategy, have not been reduced by PPI prescription, either. Squamous cell cancers of the esophagus, associated with GERD, have instead increased.
In a New York Times article of June 26, 2012, Dr. Joseph Stubbs, former president of the American College of Physicians, stated: “When people take proton-pump inhibitors, they haven't cured the problem of reflux. They've just controlled the symptoms." By utilizing Complementary Medicine to restore gastric homeostasis, the problem can be cured with a comprehensive holistic treatment protocol. Guidelines state that these acid reflux drugs are intended for short-term use, less than 12 weeks, and in that time, the patient needs to correct the homeostatic functions and avoid the serious consequences of long-term use of these drugs.
Proton-pump inhibitors (PPIs) are a broad class of commonly-prescribed drugs that include the brand named Prilosec (omeprazole), Prevacid (lansoprazole), Nexium (Esomeprazole), Protonix (pantoprazole), Aciphex (rabeprazole), and Zegarid. These drugs usually take about 3 days to work, so immediate relief after taking the drugs is not attributed to the drug action. Guidelines recommend that the lowest effective dose be used for each individual, that patients with mild heartburn or stomach acid utilize a simpler treatment protocol, and that chronic dependency be discouraged. Stopping the chronic use of PPIs is problematic, though, as a rebound acidic effect usually occurs. Because of this, a period of transition, where the patient may use herbs, nutrients medicines, acupuncture, and common antacids to modulate acid production and stomach function, and avoid acid-producing foods, such as refined carbohydrates, alcohol, coffee, etc. is recommended. Tapering the dose may be helpful. As always, a realistic benefit-risk assessment is needed, as well as a realistic program to restore gastric function. Simply stopping acid blocking drugs without a realistic plan of action is not sensible. If common side effects, such as constipation, diarrhea, irritable bowel syndrome, headaches, or the numerous effects resulting from chronic deficiency of Vitamin B12, iron, magnesium, calcium etc. are occurring, restoring gastric function and reducing or stopping dependency on proton pump inhibiting drugs may resolve these health problems.
A December 11, 2013 study published in the Journal of the American Medical Association (JAMA) noting that a 65 percent increased risk for B12 deficiency occurred in patients taking these acid inhibiting drugs for over 2 years, and more than a fourth of these patients were tested for anemia and/or memory loss, often caused by chronic B12 deficiency. In a New York Times article entitled Study Links Long-Term Use of Acid-Suppressing Drugs to Vitamin B12 Deficiency, the senior author of this study, Dr. Douglas A. Corley, which examined medical records of over 200,000 patients at Kaiser Permanente in Oakland, California, stated that this is a “potentially serious problem", and Dr. T.S. Dharmajan, director of the Wakefield Campus of Montefiore Medical Center Residency Program, in the Bronx, New York New York, stated that “physicians need to play a greater role in the discontinuation" of these drugs. Surprisingly, the B12 deficiency was most strongly noted in patients younger than 30 years old, as well, and with these drugs now available without prescription, the potential for health problems that are not knowingly associated with chronic use of the drugs is enormous. Studies in recent years have also demonstrated that there is increased risk for osteopoenia and bone fracture risk, increased risk of pneumonia, increased incidence of iron deficiency, and negative interactions with other drugs that utilize the CYP2C19 pathway of drug breakdown in the liver. The solution to this problem is to utilize Complementary and Integrative Medicine (CIM/TCM) to regain health and function of the stomach and small intestine when this problem arises, and so use the acid-suppressing drugs for the recommended amount of time only, 12 weeks or less.
When looking at the problem of gastroesophageal reflux disease, we must realize that this is a disease, and thus involves more than just high acid production that needs inhibition. Our stomachs were designed to utilize acids in a feedback mechanism, and when the function of the stomach is decreased, the entire feedback system is altered. Oversimplification of the problem is not the solution. The damage from poor stomach function and GERD therefore not only extends upward to effect the sensitive esophageal lining and upper bronchial tract, but downward, contributing also to Irritable Bowel Syndrome (IBS). To learn more about IBS, go to the article on this website on these functional GI disorders. Numerous studies now show that poor stomach acid production is causing a chain of dysfunction that eventually extends down into the bowels, and patients prescribed common medications to correct stomach acidity are often not benefited despite some symptom relief (see study cited below). Symptom relief does not necessarily signify that the underlying dysfunction and subsequent health threat is corrected. The intelligent patient will insist on proper testing and analysis, and utilize a more thorough treatment approach, including Complementary and Integrative Medicine, and the Licensed Acupuncturist, into the whole treatment protocol.
The Issue of Dysfunction in Transient Lower Esophageal Relaxations and the appropriate treatment protocol
In recent years it has been discovered that a significant number of patients that complain of heartburn and reflux, especially of an episodic or transient nature, suffer from a condition called abnormal transient lower esophageal sphinctre relaxations. These relaxations of the entry into the upper stomach allow stomach acids to travel up into the esophagus when this neurohormonal reflex becomes dysfunctional. This condition may eventually cause GERD. Studies in Great Britain, Taiwan and Australia have confirmed that mild electrical stimulation at just one key acupuncture point (P6), will reduce the frequency of these transient lower esophageal sphincter relaxations by nearly 50 percent. Other studies have demonstrated that mild electrical stimulation at just one point (ST36) will significantly regulate intestinal motility, and presumably, other neural mediated intestinal functions. Research has demonstrated that these effects occur via the autonomic nervous system and enteric plexus. This is just one important protocol that can be utilized by an evidence-based Licensed Acupuncturist and herbalist. A thorough treatment protocol with herbs and nutrient medicines to promote gastric homeostasis, or normal physiological function, clear imbalances in the symbiotic microbial colony, such as heliobacter pylori or candida species, or to address other contributing factors to poor stomach health and function, will greatly help to restore the stomach and small intestine health. Holistic protocol will allow the patient to continue in life without dependency on treatment, reduce the risk of stomach and intestinal cancers, and provide for a better quality of life.
Modern medicine has recognized the prevalence of transient lower esophageal sphincter relaxations and gastric hypofunction, but pharmaceutical treatment has presented a quandary for prescribing doctors. The drug metoclopramide (Reglan et al) was first recognized in 1964, but was rarely prescribed except in cases of acute nausea and vomiting, due to the neurological side effects from prolonged use. The FDA approved metoclopramide only for short term use of 4-12 weeks for this reason, as metoclopramide works by binding to dopamine type 2 receptors to inhibit dopamine effects, and antagonizing effects at the 5HT3 receptors while increasing effects at the 5HT4 receptors, which affects the brain, or central nervous system, as well as the gastrointestinal mesentery. This neurological blocking stopped the brain from stimulating a vomiting reflex, but over time created other neurological problems, creating guidelines that only approved short term use. The drug was useful in acute crises, but not appropriate to treat the chronic condition.
Over time, though, drug manufacturers showed that metoclopramide and similar drugs could also treat gastric hypofunction, transient lower esophageal sphincter relaxations, motion sickness, GERD, and even migraines, and pushed for expanded use and sales. Unfortunately, prolonged use came with a very significant risk of developing a neurological condition called tardive dyskinesia and dystonia, or unwanted repetitive movements, and extrapyramidal effects as well. The list of neurological side effects range from mild manifestations that are often overlooked and ignored, such as nocturnal bruxism (teeth grinding and clenching), restless leg syndrome, anxiety, attention deficit and hyperactivity disorder, idiopathic tremors, unwanted eye movements and facial tics, to more serious problems such as Parkinsonism, seizures, depression, and neurolepsy. The term tardive implies that these symptoms develop gradually and with much delay, making the connection between the drug use and the onset of symptoms unclear.
With the occurrence of a large number of lawsuits when these neurological problems were diagnosed as having been caused by metoclopramide, studies showed that most patients now took the drug for longer than 12 months, rather than the approved 4 weeks. Since the drug is now generic, the Supreme Court has been faced with two cases where generic manufacturers are attempting to exclude themselves from liability, claiming that they are not as scientific as the standard drug companies and cannot be blamed for inadequate or misleading label warnings. In other words, the drug industry is attempting to lay full responsibility on the patient to choose wisely when using drugs that were highly restricted in use, but now are easily available without a prescription, or guidance by a medical doctor, and are highly likely to cause neurological problems when taken for a prolonged period of time. The ability to now purchase metoclopramide without prescription under a large number of names makes this drug a significant threat to health, and underscores the problems the patients and consumers now face in the drug market.
Surely, trying a safer and more conservative approach to gastric hypofunction and reflux, with electroacupuncture and herbal and nutrient medicine, which is now proven to work in human clinical trials, should be encouraged in standard medicine and popular with patients, yet it is not. The reluctance to integrate Complementary Medicine, when it is proven to work in human clinical trials and laboratory settings, by modern medical doctors in the United States, is slowly being seen by patients as a failure of our medical system that is prompted by a culture of economic interests over patient health. Patients are turning more and more to drugstore herbal remedies as advertising increases, yet the sensible use of professional Complementary Medicine in this area is still slow to take hold. Hopefully, this article will provide some insight into these widespread problems of gastrointestinal dysfunction and reflux, and prompt patients to take a more proactive and informed approach to acid reflux and reflux of gastric dysfunction.
A Growing Problem with Adult Eosinophilic Esophagitis, Often Mistaken For or Occurring Along With GERD
Eosinophilic Esophagitis (EoE), often misdiagnosed as GERD, is a disease of immune dysfunction that was previously considered a rare pediatric disease, but in the last decade or so is now seen in a large number of adults. The diagnosis of this overlooked immune dysfunction is still only considered when the patients do not respond to the oversimplified treatment with gastric acid inhibiting drugs, such as the now infamous Proton Pump Inhibitors (PPI), and also then failed to get better when a surgical correction was performed. When this explosive growth in the GERD population of adult Eosinophilic Esophagitis occurred, the industry responded by quickly establishing guidelines that just used a very high dose of the PPI drugs, which for some patients temporarily relieved the symptoms, inexplicably. Since then, experts studying this complex pathology have distinguished the PPI responsive esophagitis from actual Adult Eosinophilic Esophagitis, creating even more complex confusion, and with most patients failing to find long-term relief from this high dose PPI drug regimen. This high-dose PPI regimen often just increases the many serious adverse health effects from chronic PPI use, and standard medicine then has resorted to the use of corticosteroid drugs, such as prednisone, to treat the condition. Of course, corticosteroid medication is also very problematic with adverse health effects, the chief among them immune suppression, which does not seem sensible to a majority of informed patients being treated for a syndrome of immune dysfunction. This could be called a Catch-22 treatment protocol. In addition, Eosinophilic Esophagitis may be caused by a Candida overgrowth, and corticosteroid use often results in a candidal infection. Such contradiction is rarely a deterrent to standard therapy and guidelines for most Medical Doctors, though,
Eosinophlic Esophagitis (EoE), or an abnormal excess of the white blood cells (leukocytes) called eosinophils, occurring in response to allergens, drugs, parasites of other causes, that is causing chronic inflammation of the eosphagus, is a complex disorder. Normally, tissues of the lungs, stomach and intestines are the usual residence of these eosinophils, but they can multiply in blood circulation as well, in response to infections (particularly helminth parasites in the intestines), allergic responses, connective tissue disorders, medications, endocrinopathies (hormonal imbalances), or cancers (especially leukemias). The usual diagnosis of EoE includes symptoms of dysphagia (trouble swallowing) and the sensation of glomus (food impaction discomfort), as well as the usual GERD symptoms, which may or may not be present, as well as a biopsy of the esophagus, and the exclusion of other disorders that may be causing the symptoms, such as GERD. In true Eosinophilic Esophagitis, the symptoms do not respond to high-dose Proton Pump Inhibitor (PPI) therapy, according to experts at the American Gastroenterological Association (AGA) (Glenn T. Furuta et al, 2007). Unfortunately, most of the adults finally diagnosed with this condition were treated first with high-dose PPI drugs, creating an embarrassing situation in standard medicine. Eosinophilic Esophagitis is also often seen in patients with Crohn's disease (inflammatory bowel disease, or IBD), esophagitis related to Herpes or Candida, drug-associated esophagitis, and collagen vascular disease, as well as drug hypersensitivity responses. The disease affects males more than females, happens to both children and adults, is increasing in incidence dramatically in industrialized countries, and tends to be a persistent and recurring disease. The abnormal tissues in biopsy may be seen in both the lower and middle esophagus, and often a biopsy of just the lower esophagus produces a false negative. Generally, this often overlooked pathology is a diagnosis of exclusion.
Medications that have been linked to esophagitis include pain NSAIDS such as ibuprofen and naproxen, antibiotics, potassium chloride, quinidines that treat heart problems, and biphosphonates such as Fosamax that are used to treat osteoporosis, ironically, and now used to treat obesity, again ironically. Newer antibiotics, such as Cubicin (daptomycin), a lipopeptide antibiotic, now generic (Cubist and Hospira Pharmaceuticals) and increasingly sold to counter skin problems such as acne, come with considerable risk of not only Eosinophilic Esophagitis, but stomach pain, diarrhea, and injury to the liver function, as well as neuropathy, and drug-drug negative interactions with statin drugs for cholesterol are a concern. The manufacturer, Lilly, stopped clinical trials and development because a high-dose or accumulation caused myalgia and myositis (muscle pain and inflammation) in a significant percentage of patients, but the antibiotic is now commonly used to treat antibiotic-resistant MRSA and other infections, pneumonia and endocarditis. In 2010, the U.S. FDA issued a warning that Cubicin (daptomycin) could cause a life-threatening form of Eosinophilic Esophagitis, as well as milder cases, but this has not affected sales. Other drugs have received FDA warnings for causing Eosinophilia as well, such as the antipsychotic Ziprasione, or Geodon, increasingly used for off-label conditions. Both the discontinuation or reduction in use of these drugs, as well as a holistic therapy to address the various factors that may be causing or contributing to the problem may be needed to recover. Acupuncture may not have a direct curative effect, but could work synergistically with a more comprehensive clinical strategy, resolving gastric dysfunction, clearing parasitic or fungal infection, boosting the immune responses, and treating allergies. There may not be a simple and miraculous quick cure for Eosinophilic Esophagitis, but a persistent and comprehensive course of therapy, utilizing CIM/TCM will work.
Prescription of gastric acid inhibiting drugs should have no effect on Eosinophilic Esophagitis, according to the experts cited above, but the prescription of a high dose regimen of PPI drugs is common, and 'justified' in ruling out what is called PPI-responsive esophageal eosinophilia, remarkably enough. In children, the restriction of foods and feeding with an elemental amino acid formula has shown to be extremely effective in up to 98 percent of infants, showing that altered proteins in foods are causing an allergic response with overproduction of eosinphils. With adults, this treatment is problematic, but it does show the possibility that allergies to proteins, especially in foods with altered proteins, such as high-gluten products or GMO foods. The pathology is usually multifactorial in adults, though, and a careful holistic diagnostic workup and treatment of any of the problems known to cause EoE is sensible.
The Issue of Overprescription of Gastric Inhibiting Drugs to infants improperly diagnosed with GERD
A high percentage of infants normally experience gastric reflux, usually referred to a “spit up". This occurs shortly after feeding, and is due to the liquid diet and undeveloped gastric function of the infant, which improves over time. In the past, parents just calmly dealt with this annoying habit of many babies. Today, an explosive prescription of gastric acid inhibiting drugs has occurred for these infants experiencing spit up, despite numerous studies showing that they were ineffective. A health services researcher at the University of Michigan, Dr. Beth Tarini M.D., published a study in 2013 that addressed this issue, noting that when parents were told that their infant had GERD, or that the normal occurrence of spit up was a health “problem", that these parents were significantly more interested in having their child put on prescription drug medication, even when they were told that the acid inhibiting drugs were found ineffective for this infant problem. Parents in a control group in this study that were not told that their infant had GERD were not interested in using medication to control stomach acid when they were told that these medications were found ineffective. The way the health problem was described and diagnosed largely determined the use of prescription medication to treat infants, not the actual need and efficacy of the drugs. Dr. Tarini was quoted in a June 3, 2014 New York Times article, entitled The Trouble With Labeling a Health Problem a Disease, as saying: “Our job as doctors is to make sick patients healthy, not to make healthy patients sick." Obviously, economic incentives, the way prescribing doctors are reimbursed, the way treatment guidelines are influenced, the way scientific study is influenced, and not just doing the right thing, has become a complex issue driving our use of medicine, and the way a health problem is characterized plays a large role in this equation. By becoming better informed, taking the time to understand the pathophysiology of your health issue, questioning risk versus benefit, and integrating Complementary Medicine, patients will be able to achieve a better outcome.