Reflux and Ulcers,"
Dr. David Peura, University of Virginia Health System, on-line
www.AmericasDoctor.com, June 16, 2000.
Moderator: Hello and welcome to this
evening's Q&A discussion "Acid Reflux and Ulcers" with Dr. David
Peura. Dr. David Peura has been a professor of medicine and
associate chief of the Division of Gastroenterology and
Hepatology at the University of Virginia Health System since
1996. A former consultant to the U.S. Army Surgeon General, he
is a leading expert on the Helicobacter pylori bacterium, or H.
pylori. A member of numerous professional organizations, Dr.
Peura has served as chairman of the Board of Governors and as a
trustee for the American College of Gastroenterology and as
chairman of the education committee for the American
Gastroenterological Association. Dr. Peura is a member of the
National Digestive Health Initiative (NDHI) steering committee
and directed the NDHI public education campaign for H. pylori
sponsored by the American Digestive Health Foundation. Without
further delay Dr. David Peura...
Dr. Peura: Welcome this evening. We are
going to be talking about a very common problem that most of you
or many of you suffer from or know people who suffer from:
heartburn, indigestion and ulcers. Please feel free to ask any
questions you might have, but remember on specific things you
are really going to have to see your doctor.
Guest: Does reflux inevitably lead to
Dr. Peura: Reflux and ulcer disease really
are two different things. Both are caused by acid, but ulcers in
addition are usually associated with an infection, a bacterium
called H. pylori. Getting rid of the bacteria can cure ulcers,
but it does not do anything for heartburn.
Guest: Does stress cause ulcers? If so
what can treat the ulcer?
Dr. Peura: Stress does not cause ulcers.
Stress makes symptoms worse or makes someone more aware of their
symptoms. As I noted earlier, many ulcers are caused by an
infection. Treating the infection treats the ulcers. Eliminating
acid treats the symptoms.
Guest3: Can seasonal allergies exacerbate
Dr. Peura: It is interesting that
allergies can make reflux symptoms worse in some individuals. If
they have a lot of stuffiness or postnasal drip, people tend to
swallow more and as a result they accumulate more air in their
stomachs and venting this air may promote reflux.
Guest: Why do stressed-out people always
seem to get ulcers? Is it something mistaken as an ulcer?
Dr. Peura: Stressed-out people often are
more aware of aches and pains symptoms in general. Probably,
their ulcers are more frequently diagnosed because they complain
of their symptoms to their doctors. Alternatively, their
symptoms may be due to other things other than ulcers brought on
by a "stressful lifestyle" - smoking, eating too quickly, eating
bad things, not taking time out for exercise to name a few.
There are lots of people with stress that don't have ulcers.
Guest: Can surgery be done on an ulcer?
Dr. Peura: Surgery used to be done quite
frequently for ulcers, but now that we have good medicines to
treat the infection that causes most ulcers, or to reduce acid
which causes most ulcer symptoms, surgery is done much less
frequently. Surgery now is done primarily for complicated
ulcers: those that bleed, develop scar tissue that interferes
with the emptying of food from the stomach, or the ulcers that
erodes through the lining of the intestines.
Guest2: What tests are available to
diagnose acid reflux?
Dr. Peura: The best test for diagnosing
acid reflux is a response to treatment. If you have symptoms
that suggest heartburn, your doctor may choose to treat you with
medicine to suppress acid. If this works quickly and
predictably, then your impression and the doctor's impression
that you have reflux is most likely correct. If you don't
respond to that test, your doctor can order specific x-rays, a
procedure called endoscopy where he or she can look into your
esophagus to check for irritation or damage or actually do a
study called PH monitoring to determine if the acid is actually
coming up into the esophagus. We are using these tests less
often now than we did in the past since we have such effective
therapy to treat reflux symptoms.
Guest3: Are Heidelberg capsules used to
diagnose or determine appropriate treatment for acid reflux?
Dr. Peura: I am not familiar with that
particular Heidelberg capsule.
Guest: Can surgery be used on reflux
Dr. Peura: Surgery is an alternative
treatment for reflux. We generally reserve surgery for people
who are poorly responsive to medicine or find it hard to take
medicine for one reason or another. Before surgery is done,
however, specialized tests should be ordered such as endoscopy
to look at the esophagus, a PH monitoring to confirm reflux is
present, and a motility test to ensure that the esophagus is
Guest: Can over-the-counter antacids be
over used or abused? I know they aren't abused as a drug but
maybe depended on?
Dr. Peura: Over-the-counter medications
are medicines and like any medicine that can have side effects
associated with them. They should be used as instructed on the
package. If someone needs to use them in larger quantities or
for longer periods of time than recommended, then he or she
should consult their physician since there may be other better
medications to treat the symptoms. Recently the National
Heartburn Alliance (NHBA), a group of doctors and health care
providers, has addressed some of these issues relating to
symptoms and medicines. Anyone who would like a free brochure
outlining the dos and don'ts of heartburn can call
Guest: What lifestyle changes should be
taken to avoid heartburn?
Dr. Peura: Lifestyle does not cause all
heartburn. Heartburn is due to acid coming up from the stomach
into the esophagus. Doing certain things such as avoiding large
meals, fatty foods, chocolate, peppermint, avoiding lying down
after meals, can all help prevent acid from coming up the
esophagus and reduce heartburn. Losing weight, moderate
exercise, not smoking is also helpful in some people in
improving heartburn symptoms. But I need to emphasize that
frequent heartburn more than three or four times per week can
signal a more severe problem and should not be treated only with
changes in lifestyle. Medications, even over-the-counter
medications, may be necessary in this situation.
Guest2: Is there another test that can be
done to diagnose acid reflux other than the endoscopy procedure?
Dr. Peura: As I noted previously, the best
test to diagnose heartburn or reflux is a trial of treatment to
suppress acid. This actually turns out to be better than
Guest3: What is your opinion regarding the
relative efficacy of Prilosec® as compared to Pepcid® or other
prescription medicines to treat reflux?
Dr. Peura: Prilosec is in a class called
proton pump inhibitors. There are now four medicines in this
class. They are the most effective treatments available for
reflux. Pepcid is in a class of drugs called H2 blockers. These
drugs are also effective in treating symptoms, but they are not
as strong as the proton pump inhibitors.
Guest6: I just had an esophagram done and
they found I have a small ulcer. What can be done about that?
Dr. Peura: It is difficult to give you a
specific recommendation because I do not know the size and exact
location of the ulcer. However, if the ulcer is in the
esophagus, it may be due to reflux of acid and treatment with a
proton pump inhibitor may help it heal. However, you need to
check with your doctor about undergoing an endoscopy to actually
look at the ulcer and biopsy it if needed.
Guest2: I am presently taking two Prilosec
at bedtime, but I still have problems getting very sick at
Dr. Peura: Again, it is difficult to give
you a specific recommendation. However, the proton pump
inhibitors like Prilosec appear to be most effective when given
before a meal. Generally, if they are dosed twice daily, one is
taken before breakfast and one before the evening meal. Taking
two at bedtime may not be the most effective way to dose the
drug. You need to check with your doctor for more specific
recommendations, especially since you are continuing to have
symptoms despite two doses a day.
Guest3: What are the other three proton
pump inhibitors so that I may investigate their relative merits
with my physician?
Dr. Peura: The four proton pump inhibitors
are Prilosec, Prevacid, Aciphex®, and Protonix®. Given in
equivalent doses, studies suggest that they are all effective,
and all very safe.
Moderator: Are there any further questions
concerning reflux, heartburn, or ulcers for Dr. Peura?
Dr. Peura: For people that are interested
in general information about heartburn, what causes it, what you
can do to help treat and prevent it can call 1-800-NHBA-INFO for
a free consumer brochure. This is put out by the National Heart
Burn Alliance, which is a group of physicians and other health
care providers that are joining together to provide credible
information about heartburn and its treatment. This is
particular important because heartburn is such a common problem
effecting 20 to 40 percent of adult Americans.
Moderator: I have difficulty swallowing
solid food. My doctor says it is due to reflux; what can I do?
Dr. Peura: Your doctor is correct that
difficulty swallowing can be due to reflux. Acid that has come
into contact with the esophagus over a long period of time can
lead to scar tissue formation and narrowing. However, difficulty
swallowing can also be a sign of cancer. So that anyone with
this complaint needs to check with the doctor and consider
having an x-ray study or having an endoscopy performed before
treatment for reflux is initiated.
Guest3: Is there any correlation between
acid reflux severity and cancer of the esophagus?
Dr. Peura: A recent study published in the
New England Journal of Medicine which was done in Sweden
suggested that people who have frequent heart burn, more than
three to four times per week, heartburn that has been going on
for many years, more than 5 to 10 years, and those with
particularly severe symptoms were at higher risk of developing
cancer of the esophagus. That is why people with frequent severe
symptoms that have been going on for a long period of time need
to consult their doctor for advice in managing their problem.
Hopefully this will prevent the development of subsequent
Guest6: What is a proton pump inhibitor
Dr. Peura: A proton pump inhibitor is a
class of medicine that inhibits the stomach's acid reduction.
The stomach makes acid every day in response to eating or even
thinking about eating. This acid is very corrosive, much like
battery acid and if it washes back into the esophagus, it can
cause irritation and heartburn. Proton pump inhibitors prevent
the acid from being produced in the stomach. Therefore, they can
treat reflux-related irritation and symptoms.
Moderator: Since there are no further
questions I will get Dr. Peura's closing remarks...
Dr. Peura: Since there are no further
questions, we can end this session a bit early. There is never a
good time to suffer from heartburn or from ulcer symptoms.
However, in this day and age we have good medication not only to
treat heartburn symptoms, but good antibiotics to cure the
infection that causes ulcer disease. Heartburn and indigestion
are not a normal way of life. There is no reason that anyone
needs to suffer. Consult your doctor because there is good
medication available for your problem. Good night and be careful
out there. Thank you.
Moderator: Thank you for joining evening's
Q&A discussion, "Acid Reflux and Ulcers" with Dr. David Peura.
Dr. David Peura has been a professor of medicine and associate
chief of the Division of Gastroenterology and Hepatology at the
University of Virginia Health System since 1996. A former
consultant to the U.S. Army Surgeon General, he is a leading
expert on the Helicobacter pylori bacterium, or H. pylori. A
member of numerous professional organizations, Dr. Peura has
served as chairman of the Board of Governors and as a trustee
for the American College of Gastroenterology and as chairman of
the education committee for the American Gastroenterological
Association. Dr. Peura is a member of the National Digestive
Health Initiative (NDHI) steering committee and directed the
NDHI public education campaign for H. pylori sponsored by the
American Digestive Health Foundation. Thank you all once again
for joining our chat. Have a nice evening!
Reviewed by Dan Morhaim, M.D. June 2000