Author: Dr. Kwiatt

Acid Reflux Medications: What are the risks?

There are a lot of questions now about the class of acid reflux medications called proton pump inhibitors (PPIs).  PPIs include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), and Protonix (pantoprazole).  As acid reflux and stomach ulcers are common health conditions, many people take these medications.  There have been several news stories raising concerns about these medications and many patients coming to see me in the office ask me about these drugs,

Why do people take PPI medications?  Common reasons to take PPI medications include:

Acid reflux – Medication reduces stomach acid, and hence helps the symptoms of burning and discomfort.

Stomach ulcers- By reducing stomach acid, the PPI helps ulcers heal.  Can also prevent recurrent ulcer bleeding in people that need to take blood thinners and medications like aspirin or ibuprofen (NSAIDs)

Upper abdominal pain (also known as dyspepsia)- medication for a short duration can relieve discomfort in the upper gut.

Barrett’s esophagus– reduced acid helps eliminate damage to esophagus tissue.

There are some clear health benefits to a PPI medication.  Acid reflux can be associated with a condition call Barrett’s esophagus which can lead to esophagus cancer.  Severe issues with acid reflux can cause pain, sleep disturbance, and poor quality of life.  Stomach ulcers can cause internal bleeding.

So what are the risks?

A study in the journal JAMA Neurology (JAMA Neurol. 2016;73(4):410-416. doi:10.1001/jamaneurol.2015.4791)  raised concerns that PPI use may be associated with dementia.  The researchers obtained data on patients in a German health insurance plan and compared the rates of dementia on patients that took PPI to patients that did not take PPI.  They did find that there was a weak statistical association with higher rates of dementia in patients on PPI medications.   The issue with this study is that the patient’s on PPI medications in the study also had higher rates of stroke, heart disease, and use of multiple medications which can also cause dementia.  These sort of research studies need to be interpreted with caution.  A correlation does not equal a cause.  You can ask my children to tell you about this.  If you wear the green Packer jersey and they win this week, it does not mean that the Packers will win again next week if you wear the same jersey.  Correlation does not equal cause. (Reference: 2016 NFC Championship game)

What should you do if you are on a PPI?

The most important thing to do would be to talk with the doctor prescribing the medication.  If you are taking over the counter PPI medications, you should consider discussing your symptoms with a doctor.  Even though I do not think the study on dementia was well designed and valid, I do like that the study has opened many discussions and has encouraged patient’s to ask questions.  “Why am I taking this medication, doc?” is a question you need to know the answer for every pill bottle in your medicine cabinet.

For patients with GERD, I typically advise them to try and go off PPI medication and see how they feel.  I advise this more for cost and simplicity; not due to concerns about dementia.  If frequent issues with reflux return, then resuming the PPI for 2-4 weeks at a time for treatment tends to control the symptoms.  This works for most patients.  For patients that have issues with symptoms multiple times a week whenever they are off PPI, long term use may be indicated.

For patient’s with Barrett’s, it is advisable to stay on the medication as Barrett’s can cause cancer.

For patient’s that take blood thinners and have had issues the stomach ulcers in the past, there is a clear benefit to remaining on the medication.

What is rebound reflux?

Sometimes stopping PPI medication abruptly can cause what is called a rebound reflux.  After long term PPI use, patients can have a temporary increase in reflux symptoms.  This will typically resolve with time.  Sometimes weaning the dose of the medication or changing to every other day dosing first can help with rebound.  Using milder over the counter antacids can also help with this while coming off PPI.

My advice is in line with the American College of Gastroenterology’s recommendations.  For more information:

http://acgblog.org/wp-content/uploads/2016/05/Loren-Laine-Long-Term-PPIs-AJG-04262016.pdf

Testing for Celiac Disease

There are a variety of tests available for celiac disease. Confirming a diagnosis of celiac disease is important, as there can be some implications of a confirmed diagnosis of celiac disease versus “gluten intolerance”. Patients with celiac disease are at risk for certain types of cancers, nutritional problems, and diminished bone density. Knowing for sure is very important as patients with a confirmed diagnosis of celiac disease require monitoring by a physician. Patients with celiac disease also need to be 100% gluten-free in regards to diet.

“Gluten intolerance”, also known as “non celiac wheat sensitivity”, causes people health issues or digestive distress when they are exposed to gluten. People with gluten intolerance do not have a confirmed diagnosis of celiac disease. Patients with gluten intolerance do not always need to be 100% gluten-free. Patients with gluten intolerance do not require the same level of monitoring that a patient with celiac disease would require. Both conditions can make people feel rather sick.  The symptoms of gluten intolerance can mimic other serious health issues, hence it is important to seek a formal opinion from a doctor.

Simply feeling better on a gluten-free diet does not constitute a diagnosis of celiac disease.

This has been shown in medical research. (Am J Gastroenterol 2011;106:508–514; Scand J Gastroenterol 2008;43:1311–1314.) Other health conditions including irritable bowel syndrome can improve on gluten-free diets.

Given these factors, formal testing is important. There are 2 types of tests for celiac disease. It is important to know that both are measuring the body’s response to gluten. In order for proper testing and confirmation of a diagnosis of celiac disease, the patient must be exposed to gluten.

1. Labs. A tissue transglutaminase antibody is most sensitive lab test for celiac disease. There are older antibody tests that are still available. We typically only use these older antibodies in certain clinical situations.

2. Biopsies of the small intestine. A biopsy of the small intestine enables the doctor to see how the small intestine is reacting to gluten. Biopsies of the small intestine are the most accurate test. The endoscopy will show breakdown of the intestine lining and the biopsy will show inflammation as well as breakdown of the intestine cells.  An adequate number of biopsies is required to make a proper diagnosis. Typically this is 6 specimens. Biopsies are taken during an upper endoscopy procedure.

Endoscopic pictures and biopsy example of celiac disease.

I typically advise patients not to start a gluten-free diet until they have at least considered laboratory testing for celiac disease. If somebody is already on a gluten-free diet the standard labs and biopsies are rendered inaccurate. There is a genetic test we can do for celiac disease but this only rules out celiac disease it does not rule it in. Establishing a diagnosis of celiac in a patient already on a gluten-free diet requires the patient to ingest at least one serving of gluten per day for at least 4 weeks in order to measure the body’s response to gluten.

The bottom line is to consult with a physician on testing for celiac prior to starting a gluten free diet.

 

Video of me discussing these tests can be found here.

 

Gluten Free Bread

“I can’t eat bread?!?”  This is the most common thing I hear when I break the bad news to a patient who has celiac disease.  We most often associate celiac disease and gluten with not being able to eat bread, even though wheat and gluten is found in many other food products.

Gluten free bread is tricky.  There are some decent pre-made breads that can be found in most grocery stores, but the good ones can be hard to find.  Many need to be kept frozen, some expire quickly, and some frankly just are not that good.

Why is gluten free bread so crumbly?  Ask anyone with celiac and they can tell you stories of crumbly bread that disintegrates when you pick it up. Gluten protein gives wheat containing breads the sticky, doughy properties that we most associate with bread’s texture.  Gluten free flours and starches can be used to make baked goods, but they usually rely on using multiple combinations of substitute flours and xantham gum to obtain that stickiness.  Some gluten free breads are heavy in starch and low in dietary fiber.

There are some amazing gluten free bread recipes on several blogs and in several cookbooks.  Due to the number of ingredients and time involved, they are not always realistic solutions for a mid week sandwich fix in our house.  Using a bread maker and a bread mix seems to hit the sweet spot for our family and gluten free bread.  Store bought is pricey, high maintenance, and sometimes not that good.  Scratch bread takes too long and has too many ingredients.  A gluten free bread mix and a bread machine hits the sweet spot of ease to make and freshness.  It is also not that crumbly and has as much fiber as normal wheat bread.  My youngest kid who does not have celiac requests this bread over wheat bread.

To make gluten free bread all you need is:

  • Pamela’s Gluten Free Bread Mix
  • 2 eggs
  • 1/3 cup of oil
  • Warm water
  • Bread machine (does not need a gluten free setting). Nothing fancy; models less than $70 will do.  A good gift for somebody who is gluten free in your life.
  • 2 cup measuring cup.

The instructions on the package are easy to follow.  I also have a video to walk you through it if you would like to try.

Gluten Free Bread How to Video

I typically wrap the bread in foil or put in a large ziplock bag.  It can be left on the countertop and does not need to be frozen or refrigerated.

Enjoy!

About this blog

I am a board certified gastroenterologist working in Southeastern Wisconsin with GI Associates.  I have a special interest in celiac disease and gluten related issues.

After being in GI practice for several years my wife began having digestive issues. Evaluation eventually led to a diagnosis of celiac disease ( TTG over 100 and severe villous atrophy on biopsy). We were shocked.  As a Gastroenterologist I was knowledgeable about the diagnosis of celiac and I knew that a strict gluten fee diet was needed. I had no idea what it was like for a patient and a young family to navigate the diet and lifestyle. The experience of being on  the “other side of a diagnosis” was difficult. On our journey, my wife taught me so much about handling a difficult diagnosis with grace. We have used what we have learned to share with my patients more practical approaches to handling celiac disease and gluten free diets.  The learning curve can be steep but, we hope that we can ease some of the initial shock and help you to feel empowered to put you on the path to good digestive health.

Overall, this experience has given me a unique perspective.  As a GI specialist, this drives my desire to focus on the latest science and research surrounding celiac disease.  As a supportive family member, it has helped me learn the day to day struggles of living with a chronic GI illness that must be managed with a strict diet.  I hope to share in my experience as both a physician and as a family member.  This blog will focus both on science as well as day to day life with celiac disease and other digestive health problems.