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Irritable Bowel Syndrome (IBS) and Small Intestine Bacterial Overgrowth (SIBO)

As those who suffer from IBS know, IBS is a frustrating and chronic condition which can cause constipation, bloat and/or diarrhea, along with other bothersome symptoms and often-times varied food intolerances. Though basically we still don’t know what causes IBS, there are new ideas that are being studied and which may lead to new treatments. One such idea relates to small intestine bacterial overgrowth (SIBO).

What is SIBO?

We’ve long known that the small intestine (the fifteen feet or so beyond the stomach, where food is absorbed) stays fairly free of bacteria, compared especially to the colon (large intestine), which has enormous amounts of bacteria. We know that if large amounts of colon bacteria grow inside the small intestine that food digestion can be altered, abnormal amounts of gas and other chemicals can be released and that some individuals develop diarrhea. However, there is now good evidence that modest amounts of SIBO may occur in at least some—perhaps most—sufferers of IBS. Some cases follow a bad but acute “ stomach flu”; others for unknown reasons, but in either case, the small intestine may fail to do its normal “housekeeping,” in which strong contractions sweep all the way down from stomach to colon and push food debris and bacteria down into the colon. SIBO can then result, which may release gas (methane and hydrogen particularly) inside the small intestine, where gas doesn’t belong normally. The methane, in turn, seems to have a further slowing effect on intestine function. The result: bloat and constipation, even though the anatomy looks fine. Others may get diarrhea from the disturbances in nerve and bacterial balance. The intestine becomes excessively sensitive and irritable in its behavior. This theory is still controversial but there is good evidence supporting this. Researchers have even developed models in animals that support this theory, and more research is underway to understand why some people are susceptible, some not, and why different symptom patterns occur.

Is there a test for SIBO?

Yes, but not a test that is necessary in every case in order to try treatment. In fact, the most “specific” test, of quantitative cultures of bacteria deep within the small intestine, is not practical or sensible. When we feel it is very important to test for before treatment, we refer patients to our specialty lab for a “breath test”. After some diet preparation and attention to what medicines you might be taking, a drink of a precise dose of a sugar solution is taken (lactulose, sometimes glucose). If there is significant amounts of bacteria, or very abnormally fast transit through the small intestine, bacteria break down the non-absorbed sugar and release hydrogen and sometimes methane; the gas concentration is measured in samples of breath periodically over about 2 hours. An abnormal pattern of gas detected is evidence of SIBO. The test is NOT 100% accurate or specific, but a positive test helps confirm the idea SIBO is present; a negative test helps us know that SIBO is very unlikely. The test is harmless and easy to do, just takes time. We provide the SIBO breath testing through our inSite lab, preferably with a take-home kit for which we have an instructional video; there is a modest fee for the convenience of the home test kit. We do offer the option of going to our lab to have the test administered if you wish. HMO patients need to have prior authorization for the test.

What do I do about my IBS?

If we believe it may be useful to treat the possibility that SIBO is causing or contributing to symptoms, there are several steps we need to follow:

1. Treat the bacterial overgrowth with an antibiotic that eliminates the abnormal bacteria in the small intestine while trying to leave alone the “healthy normal” bacteria in the colon. The best “traditional” antibiotic for this appears to be generics of the brand Augmentin (amoxicillin + clavulanate), taken 2 or 3 times daily for 7-14 days. However, some people are allergic to Penicillin/Ampicillin, some will get diarrhea as a side effect, and rarely a form of colitis (inflamed colon lining) that can become severe, though quite treatable. A newer antibiotic named rifaximin (Xifaxan) seems unique in type and is essentially not absorbed from the intestine, doesn’t disturb the “good bacteria” as much as Augmentin, but is unfortunately expensive (and seems to require a 550 mg dose three times a day for 14 days, at retail cost of $1,400!!). The FDA has OK’d rifaximin for IBS with diarrhea, but due to its expense, many health plans don’t want to pay for it. We’ll assist as best we can in getting treatment authorized, often by going through a specialty pharmacy good at working through these preauthorization issues. We have very limited samples, copay discount coupons may be available, or can steer you to the Xifaxan website of the Salix company to see if they have special programs. We encourage the use of the “GoodRx” app or website to compare pharmacy costs with online sources like Costco.com. In some cases, mainly with constipation the main symptom and positive methane breath test results, we give Neomycin antibiotic along with the rifaximin.

2. We also need to try and get the small intestine to “keep clean” by stimulating the contractions that normally sweep the bacteria back down into the colon. We use a small dose of the antibiotic erythromycin for this purpose, usually ½ of a 250 mg tablet taken at bedtime. In small doses, it seems to reduce bloaty discomfort and at night seems to turn on the small intestine “housekeeping” function—we are not using it as an antibiotic but as a “pro-motility” drug. We don’t know how long we need to use erythromycin for—perhaps indefinitely if the results stay good.

3. We know that SIBO may come back, particularly if the “housekeeping” stops happening! This means that some people may need repeated courses of antibiotic(s). The effectiveness and safety of repeated courses appears good, particularly for IBS with diarrhea.

4. As always in IBS, we also need to address issues like stress, which can intensify symptoms of IBS; and address diet, which should be balanced, with regular meals consumed slowly, avoiding too much fat, and sometimes spicy food or lactose (milk sugar). Less “gas forming” foods (navy beans, cabbage, raw bran) is sometimes advised, along with restriction sometimes of a broad range of “FODMAP” foods (see our Low FODMAPS diet). Some people need to limit gluten (the main protein in wheat products).

5. Sticking closely to the medications prescribed, and then following up after a few weeks time is extremely important. We need to see if the SIBO treatment seems to make a big impact on symptoms, then on whether the symptoms stay away long enough to be convinced the treatment was really effective, and that wasn’t just a random fluctuation in the amount of IBS symptoms. We’ll still use other approaches to IBS in many cases.

While we don’t yet have a “cure” for IBS, we hope that the theory of SIBO explains many cases of IBS, because this would make us optimistic that treatment described here can offer a new approach to an old stubborn problem.

Eosinophilic Esophagitis

Eosinophilic esophagitis (“EE”) is one of many types of esophagitis (inflammation of the esophagus). It is not as common as acid reflux esophagitis but has many of the same symptoms. In many cases, in fact, there is a combination of acid reflux and “EE”. EE is caused by an abnormal accumulation of eosinophils in the lining of the esophagus (swallowing tube). Eosinophils are a type of blood cell that can be seen in the esophagus lining, but usually very few are visible under the microscope. In EE these cells are present at an increased level. The reason for this increased accumulation is unknown. Often individuals with eosinophilic esophagitis have allergies or an allergic disorder (i.e. asthma, allergic rhinitis, urticaria, eczema etc., sometimes only as a child). Eosinophilic esophagitis is a rare condition. Of those adults affected with EE, the majority are men in their 20-30s. Children can also be affected..

Causes

Eosinophilic gastroenteritis may be due to allergies to an as yet unknown food allergen. n many cases, people who have this kind of esophagitis are allergic to one or more foods. Some foods that may cause eosinophilic esophagitis include milk, eggs, wheat, soy, peanuts, beans, rye, and beef. However, conventional allergy testing does not reliably identify these culprit foods. People with eosinophilic esophagitis may have other nonfood allergies. For example, inhaled allergens, such as pollen, may be the cause in some cases.

Signs and Symptoms

Symptoms often include heartburn and more commonly difficulty in swallowing, or the feeling that food is getting caught or stuck in the esophagus. Chest pain that isn’t typically heartburn can occur. Children get nausea and may fail to grow normally but nausea is uncommon in adults.

Diagnostic Methods

The only way to diagnose eosinophilic esophagitis is by upper endoscopy with biopsies (tissue samples) of the esophagus. Upper endoscopy or EGD (esophagogastroduodenoscopy) is a procedure performed with intravenous (IV) sedation given to accomplish very good comfort levels, and then a small lighted tube is passed through your mouth into your esophagus, stomach and the first portion of your small intestine. The tube that is used as a camera within it and is connected to a computer. This test allows the doctor to see the lining of your esophagus, stomach and the first portion of your small intestine. Pictures can be taken and can be part of your medical record. Biopsies can be taken at the time of endoscopy. There is no pain associated with taking biopsies.Findings at the time of endoscopy can show a normal-appearing esophagus or an esophagus that appears to have many rings (somewhat like a spring). Biopsies show an increase in the number of eosinophils that are present.

Treatment

There are various forms of treatment for EE. They are as follows:

1. Acid blocker medication These are called PPI or proton pump inhibitor medications (like generics for Prilosec, Prevacid, Nexium, Aciphex, Protonix). Many patients with EE do have acid reflux, which can cause its own damage and blockage points, and likely the acid backwash weakens the resistance of the upper parts of the esophagus to the allergic inflammation.

2. Further treatment involves the use of a steroid inhaler of the medication budesonide (such as Fluticasone). This is usually done for 4-12 weeks and sometimes longer during a single course. The treatment can be repeated periodically as necessary. If recurrent use is needed, additional anti-allergy medications can be used. Sometimes, patients are referred to an allergist for additional testing or treatment, but allergy testing has a poor ability to find specific foods that are involved. Unlike inhaled steroids where a spacer is used to help get the medication into the lungs, you are to spray the medication without a spacer. This allows for the medication to be delivered to the back of your throat and swallowed. This brings the medication in direct contact with your esophagus.

To operate the inhaler:

-Shake the inhaler for 5 seconds.

-Position the inhaler with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler. Position the mouthpiece between your teeth. Close your mouth around the mouthpiece. Press down on the top of the medication canister with your index finger to release the medication.

-The medication should be taken after meals. After taking the medication you should rinse your mouth with water and spit it out. -You should avoid eating for 30 minutes after taking the medication to avoid washing the medication away.

Side effects of steroid inhalers can include the development of a yeast infection in the mouth (thrush), esophagus or respiratory tract. Other typical side effects of steroids can occur, but with a much-lessened incidence as compared to oral medication like Prednisone, because so little of the medication is absorbed. If an individual just can’t manage an inhaler, a liquid suspension of medication can be made up, usually at greater cost and only by a compounding pharmacy.

Complications of EE

The most common complication is food becoming caught in the esophagus. This can lead to erosions (irritation) or ulcerations on the wall of the esophagus.

What kind of follow up will I need or when should I seek medical attention?

Routine follow up is not required once we know that treatment is working well and you have clear guidance about how much of the time to be using the acid blocker (usually LONG TERM) and using the steroid inhaler (usually intermittently if symptoms relapse). However, if you continue to have problems despite following the recommendations, call your gastroenterologist. Go to the nearest emergency department if an obstruction causes an inability to swallow which won’t clear up within a couple of hours, or call 911 if this blockage interferes with breathing.

Fod Allergies & Intolerance

Few areas cause our patients more confusion than a food allergy, food intolerance and what this has to do with their digestive problems. Wherever you turn, there seems to be conflicting information; and your friends, relatives and lots of total strangers are happy to give you their opinions also.

Some definitions pertaining to these conditions include:

Allergy: The body’s immune system normally reacts to the presence of toxins, bacteria or viruses by producing a chemical reaction to fight these invaders. However, sometimes the immune system reacts to ordinarily benign substances such as food (example: peanut allergy) or pollen, to which it has become sensitive. This overreaction can cause symptoms from the mild (hives) to the severe (anaphylactic shock) upon subsequent exposure to the substance. An actual food allergy, as opposed to simple intolerance due to the lack of digesting enzymes, is indicated by the production of antibodies to the food allergen, and by the release of histamines and other chemicals into the blood.

Intolerance: Food intolerance is a digestive system response rather than an immune system response. It occurs when something in a food irritates a person’s digestive system or when a person is unable to properly digest or breakdown, the food. Intolerance to lactose, which is found in milk and other dairy products, is the most common food intolerance, with gas, bloat and/or diarrhea typical symptoms.

Dietitian: A trained licensed professional who is best source of detailed dietary advice when medical conditions warrant it. They must have at least bachelor’s degree & internship, continuing education.

Allergist: An MD or DO who specializes in immunology and allergy. If you have true food allergies or clear immune reactions to food, an allergist can help guide specialized testing and treatment.

Nutritionist: Anyone who advertises themselves as such. Some have very sound nutrition education and training, college degrees in nutritional sciences, for example. Others are self-taught and not had their knowledge verified by anyone! Naturopaths (alternative medicine practitioners who promote ‘holistic’ practices) often “prescribe” nutritional treatments; these individuals do have some required training and licensing in California but medical training is quite limited and qualifications vary widely. Be skeptical of “nutritionists” until you check out their training, qualifications!

Food Intolerance Overview

There are many factors that may contribute to food intolerance. In some cases, as with lactose intolerance, the person lacks the chemicals, called enzymes, necessary to properly digest certain proteins found in food. Also common are intolerances to some chemical ingredients added to food to provide color, enhance taste, and protect against the growth of bacteria. These ingredients include various dyes and mono-sodium glutamate (MSG), a flavor enhancer. Substances called sulfites are also a source of intolerance for some people. They may occur naturally, as in red wines or may be added to prevent the growth of mold. These cause asthma attacks in some.

Salicylates are a group of plant chemicals found naturally in many fruits, vegetables, nuts, coffee, juices, beer, and wine. Aspirin also is a compound of the salicylate family. Foods containing salicylates may trigger allergy symptoms in people who are sensitive to aspirin. Of course, any food consumed in excessive quantities can cause digestive symptoms. Pepto Bismol contains a form of salicylate.

How can you tell the difference between a food allergy and intolerance?

Food allergies can be triggered by even a small amount of the food and occur every time the food is consumed. People with food allergies are generally advised to avoid the offending foods completely. On the other hand, food intolerances often are dose-related. People with food intolerance may not have symptoms unless they eat a large portion of the food or eat the food frequently. For example, a person with lactose intolerance may be able to drink milk in coffee or a single glass of milk, but becomes sick if he or she drinks several glasses of milk. Allergy to actual milk protein is rare in adults; kids with this outgrow it early. Food allergies and intolerances also are different from food poisoning, which generally results from spoiled or tainted food and affects more than one person eating the food.

Diagnosis

Most food intolerances are found through trial and error to determine which food or foods cause symptoms. You may be asked to keep a food diary to record what you eat and when you get symptoms, and then look for common factors. Another way to identify problem foods is to go on an elimination diet. This involves completely eliminating any suspect foods from your diet until you are symptom-free. You then begin to reintroduce the foods, one at a time. This can help you pinpoint which foods cause symptoms. Don’t do elimination diets on your own! Get advice from physician or dietitian and monitor results with a professional only. Unwise elimination leads to compromised nutrition and a poorer quality of life.

Treatment

Treatment for food intolerance is based on avoiding or reducing your intake of problem foods and treating symptoms when they arise. Small exposures are usually not a problem.

Prevention

Taking a few simple steps can help you prevent the symptoms associated with food intolerance. Learn which foods in which amounts cause you to have symptoms and limit your intake to amounts you can handle. When you dine out, ask your server about how your meal will be prepared. Some meals may contain foods you cannot tolerate and that may not be evident from the description on the menu. Learn to read food labels and check the ingredients for problem foods. Don’t forget to check condiments and seasonings. They may contain MSG or another additive that can lead to symptoms.

Reading Food Labels

Food labels are required to list whether they contain even traces of any of the MOST COMMON foods that can cause serious allergic reactions. If you are allergic to something else, you’ll need to routinely look through the entire food label and recognize terms similar but not the same as what you react to—and avoid the product. Many smart companies now indicate if their food might have been prepared on equipment that also is used for foods with the major allergens, e.g. nuts.

Food Allergies Overview

A food allergy is an exaggerated immune response triggered by eggs, peanuts, milk, or some other specific food. Eight foods account for 90% of all food-allergic reactions. They are milk, egg, peanut, tree nuts, fish, shellfish, wheat, and soy. Food labels MUST list whether a food contains any of these!

Causes

Normally, your body’s immune system defends against potentially harmful substances, such as bacteria, viruses, and toxins. In some people, a substance that is generally harmless, such as a specific food, triggers an immune response. The cause of food allergies is related to your body making a type of allergy-producing substance called immunoglobulin E (IgE) antibodies to a particular food. Although many people have a food intolerance, food allergies are much less common (perhaps 2% of adults; most childhood allergies are outgrown by age 4-6!!). In a true food allergy, the immune system produces antibodies and histamine in response to the specific food. Any food can cause an allergic reaction, but a few foods are the main culprits. In children, the most common food allergies are to Eggs, Milk, Peanuts, Shellfish (shrimp, crab, lobster, snails, clams), Soy, Tree nuts, Wheat. Allergies to peanuts, tree nuts, and shellfish tend to be lifelong. In older children and adults, the most common food allergies are: Fish, Peanuts, Shellfish, Tree nuts, Food additives — such as dyes, thickeners, and preservatives – may rarely cause an allergic or intolerance reaction.

An oral allergy syndrome may occur after eating certain fresh fruits and vegetables. The allergens in these foods are similar to certain pollens. Examples are ragweed pollen/apple; tree (birch, others) pollen/apple, pear, carrot, celery; mugwort pollen/celery, some spices; grass pollen/fig, tomato, melon. Digestive or lung symptoms are rare.

Latex-food allergy syndrome: about half of people with latex allergy may react to banana, avocado, chestnut, and kiwi; and get an itch, eczema rash, mouth-face swelling, asthma reaction, GI upset, and anaphylaxis. Many Americans believe they have food allergies, while in reality, fewer than 1% have true allergies. Most people’s symptoms are caused by intolerances to foods such as Corn products, Cow’s milk, and dairy products (See: Lactose intolerance), Wheat and other gluten-containing grains (See: Celiac disease)

Symptoms

Symptoms usually begin immediately, within 2 hours after eating. Rarely, the symptoms may begin hours after eating the offending food. Key symptoms include hives, hoarse voice, and wheezing.

Other symptoms that may occur include:

• Abdominal pain/cramps often with vomiting and/or diarrhea
• Diarrhea usually with stomach cramps
• Difficulty swallowing
• Itching of the mouth, throat, eyes, skin, or any area (oral allergy involves itchy lips, tongue, throat and sometimes swollen lips, without other reactions).
• Light-headedness or fainting
• Nasal congestion
• Runny nose
• Swelling (angioedema), especially of the eyelids, face, lips, and tongue
• Shortness of breath

Prognosis

Avoiding the offending foods may be easy if the food is uncommon or easily identified. However, you may need to severely restrict your diet, carefully read all package ingredients, and ask detailed questions when eating away from home.

Complications

Some complications include:

Anaphylaxis is a severe, whole-body allergic reaction that is life-threatening. Although people with oral allergy syndrome rarely have an anaphylactic reaction, they should ask their doctor whether they need to carry injectable epinephrine. Food allergies can trigger or worsen asthma, eczema, or other disorders.

Tests and Diagnosis

In severe reactions, you may have low blood pressure and blocked airways. A blood or skin test can be done to identify elevated antibody levels (particularly IgE) and confirm that you have an allergy. With elimination diets, you avoid the suspected food until your symptoms disappear. Then the foods are reintroduced to see if you develop an allergic reaction. In provocation (challenge) testing, you are exposed to a suspected allergen under controlled circumstances. This may be done in the diet or by breathing in the suspected allergen. This type of test may provoke severe allergic reactions. Only a doctor should do the challenge testing. Never try to deliberately cause a reaction or reintroduce a food on your own. These tests should only be performed under the guidance of a health care provider — especially if your first reaction was severe. There are three common types of allergy testing: skin prick test, blood test, and food challenges. An allergist can perform these tests, and they can also go into further depth depending on the results.

Skin testing on the arm is not as effective as other tests. For skin prick tests, a tiny board with protruding needles is used. This test only works for IgE antibodies. Allergic reactions caused by other antibodies cannot be detected through skin prick tests. Blood testing is another way to test for allergies, but it only detects IgE allergens and does not work for every possible allergen. RAST, Radio-Allergo-Sorbent Test, is used to detect IgE antibodies present to a certain allergen. The score taken from the RAST test is compared to predictive values, taken from a specific type of RAST test. If the score is higher than the predictive values, there is a great chance the allergy is present in the person. One advantage of this test is that it can test many allergens at one time.[29]. It isn’t uncommon that RAST tests don’t correlate well with actual reactions to food!!

Food challenges test for allergens other than those caused by IgE allergens. The allergen is given to the person in the form of a pill, so the person can ingest the allergen directly. The person is watched for signs and symptoms. The problem with food challenges is that they must be performed in the hospital under careful watch, due to the possibility of anaphylaxis. It can be highly subjective or biased.

The best method for diagnosing true food allergy is to be assessed by an allergist.

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) is one of the most common chronic digestive disorders seen in clinical practice today. GERD occurs when stomach contents leak back into the esophagus. Normally, this backup of acid occurs briefly in most people. It becomes a disease when it occurs frequently, causing damage to the actual tissue of the esophagus. The tissue damage leads to symptoms, most common of which is heartburn.

Causes

There are many causes for GERD. Muscle weakness of the Lower Esophageal Sphincter (LES) valve is one cause. The LES is found between the esophagus (swallowing tube) and the stomach. The LES is meant to close when food reaches the stomach after a meal. With muscle weakness, the LES does not close properly, either because it is too loose or too wide – leading to acid reflux. In turn, this damages the lining of the esophagus and its nerve endings, which sense various degrees of pressure and acidity.

Reflux occurs commonly from over eating. Reflux can also occur as a response to certain types of foods, stress, or by the effects of excess weight. Reflux can also be caused by structural abnormalities such as a hiatal hernia. In this case, the stomach is pushed up through a weakening in the diaphragm. Many persons with hiatal hernias will experience some degree of gastroesophageal reflux.

Risk Factors

Factors that induce GERD are foods and drinks with high fat, caffeine, and acidity. These include alcoholic drinks, citrus fruits, and tomato-based products. Conditions such as obesity and pregnancy can also increase the risk for GERD. Lifestyle factors such as weight gain, smoking, and eating close to bedtime can also increase the risk for GERD.

Signs & Symptoms

The most common symptom of reflux is heartburn – a feeling of burning and/or pressure in the chest spreading toward the throat or sternum. Other symptoms may include the sensation of food backing-up (regurgitation), excessive belching, and difficulty swallowing (dysphagia). Persistent cough, sore throat, and hoarseness sometimes occur.

Screenings & Diagnostic Tests

Classic GERD is diagnosed by taking a detailed medical history and is confirmed by a complete response to a PPI (Proton Pump Inhibitor) Test.

A detailed medical history: Discussing symptoms, dietary habits and past treatments will help diagnose the presence of reflux.

PPI Test : Patients who do not respond to PPI Therapy are less likely to have GERD.

Endoscopic Examination :typical cases of GERD can be diagnosed and treated without endoscopy. However, endoscopy can sometimes be recommended to assess for complications, contributing causes of reflux such a hiatal hernia, and treatment guidance.

Barium X-Ray and Upper GI Series: A barium X-ray is a radiographic test of the GI tract. The barium mixture is used to coat the walls of the digestive tract. This type of test is rarely recommended.

Esophageal pH Monitoring: The procedure measures the reflux of acid that flows into the esophagus. It is usually performed by placing a thin catheter through the patient’s nostril and down into the esophagus. The catheter contains sensors that record reflux of acid over a 24 hour period. An alternative method involves placement of a sensor capsule just above the lower esophageal sphincter.

Treatment

Once reflux is diagnosed, an anti-reflux treatment program can begin. Treatment of esophageal reflux consists of two major components; lifestyle changes and medications.

Diet & Lifestyle

Cut down or quit smoking: Cigarettes and other types of tobacco products can decrease LES pressure and increase acid secretion that aggravates reflux and contribute to ulcer formation.

Avoid large meals and overeating: Wait at least 3 hours after meals before lying down or engaging in physical activities that increase pressure on the stomach and may force acid back into the esophagus.

Elevate the head of your bed: Elevating the head of your bed four inches or more (depending on your doctor’s recommendation) will help prevent reflux.

Lose excess weight:Shedding even 8-10 pounds can cause a major improvement in reflux symptoms.

Wear comfortable clothing to minimize your reflux problem.

Limit or avoid alcohol, coffee, fatty foods, citrus juices and tomato sauce.

Medications

The goals of treatment of GERD are to relieve symptoms, heal the esophageal lining and reverse and prevent damage even when symptoms are not active. So in addition to diet and lifestyle changes, your doctor might recommend medications to help fight reflux. There are three main types of medications that neutralize or prevent acid.

Acid neutralizers: Antacids are usually the first drugs recommended by physicians to relieve sporadic heartburn and other mild GERD symptoms. They are also used to treat breakthrough symptoms which can occur despite taking acid blocker medications. Side effects of acid neutralizers, such as diarrhea and constipation, are associated with magnesium and aluminum salts. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids can also be a supplemental source of calcium. They seldom cause constipation.

H2 blockers reduce, but do not completely block, acid production by the stomach. These drugs provide short-term relief. Some products are combined in one pill with an antacid.

Proton pump inhibitors (PPI’s) PPI’s are much stronger at blocking acid production than H2 blockers, and one dose typically lasts 24 hours. PPI’s include:

• Omeprazole (Prilosec, Zegerid)
• Lansoprazole (Prevacid)
• Pantoprazole (Protonix)
• Rabeprazole (Aciphex)
• Esomeprazole (Nexium)
• Dexlansoprazole (Dexilant)

Surgical Options

Though we seldom recommend it, some patients can benefit from surgical treatment for their GERD.

Nissen Fundoplication or “wrap” operations: Involves pulling the hiatal hernia part of the stomach back down into the abdomen, and wraps the upper end of the stomach around the lower end of the esophagus. Both aspects help create a better-functioning lower sphincter zone, so that reflux diminishes greatly.

LINX Procedure: Involves placement of a bracelet with magnetic beads at the gastroesophageal junction to constrict the loose LES valve.

Treatment Outlook for GERD

Although long-term treatment of GERD can be challenging, currently available medications appear to be safe for long term use. It is important to remember that dietary and lifestyle changes are crucial in managing symptoms of GERD and may be better effective at helping patients wean off medical therapy.