Year: 2002

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Stomach Bacteria (H.pylori)

Helicobacter pylori (H pylori) is an organism found in stomach. It is estimated that more than half the world’s population is infected with this bacteria. That includes 20 to 40 percent of Canadians.

Usually, infected individuals have no symptoms and develop no problems as a result of this. Only 15 percent of infected individuals develop clinically significant H pylori related disease in their lifetime – stomach ulcers, gastritis and cancer.

Is this bacteria a normal inhabitant of stomach since so many people seem to carry it? Or people are infected from others? The answer is not very clear.

Since the bacteria have potential to cause illness, should we screen everybody for this bug?

Here is what a review article in the Canadian Journal of Gastroenterology says:

-Consensus conference of the Canadian Helicobacter Study Group does not recommend screening in asymptomatic individuals.

-Recommendation is to screen and treat all patients with gastric or duodenal ulcer whether they are symptomatic or asymptomatic.

-There is controversy as to whether patients with dyspepsia (indigestion) benefit from H pylori eradication. It seems that a small number (up to 15 percent) of such patients benefit from treatment.

How can we test for H pylori infection?

A blood test can tell us whether one has been exposed to the infection. If this test is negative then there is 90 percent chance that there is no infection. A positive blood test does not mean that you are currently infected. Under the age of 50, this test should be good enough depending on patient’s symptoms.

Urea breath test is superior to the blood test and is another simple way to check for infection. It has less than 10 percent false negative and false positive results. But in Medicine Hat, most patients end up getting the most expensive invasive test called gastroscopy. Why? Because the other two tests are not readily available.

What to do if infection with H pylori is detected?

The review article says that testing should not be performed to detect the presence of H pylori without an intention to treat if the test result is positive. Recently published guidelines recommend treatment of asymptomatic patients whose infection becomes known. In patients with peptic ulcer disease, eradication of H pylori infection is cost effective.

Treatment is with an acid suppressant (proton pump inhibitor) and two antibiotics for seven days. This is called triple therapy. It is almost always curative, and the infection almost never recurs in Canadian adults, but research says that eradicating the bacteria in the absence of peptic ulcer rarely fixes the problem of indigestion.

Are we smarter today than 17 years ago when the bacterium was first discovered?

In many ways, yes! Now we can cure peptic ulcer without surgery. But new studies suggest that treating this bacterium may increase the risk of esophageal ulcers and cancer. If you don’t treat it then there may be a risk of getting stomach cancer! Go figure!

Who said doctors know everything? In the last 20 years, this is one of the most important discoveries in medical science. But there are many unanswered questions.

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Heart Burn

Heartburn is a common condition and people often ask me: Dr. B, why do I have heartburn? What can I do about it?

“Heartburn is a serious symptom that merits more attention from patients and physicians,” says an editorial in the New England Journal of Medicine (NEJM).

The editorial says that heartburn is the hallmark of reflux from stomach to esophagus, a disorder that may lead to esophagitis (inflammation of the gullet), progressing in some patients to cancer of the esophagus. The cancer is preceded by a condition called Barrett’s esophagus.

Heartburn (also known as GERD or gastro-esophageal reflux disease) is a condition in which an individual experiences a sensation of burning from the stomach to the throat. This is due to the reflux of acid, sometimes mixed with bile and food. This is accompanied by bitter taste in the throat and the mouth. Sometimes coughing spells follow the reflux as the acid spills over into the wind pipe. This may also result in pneumonia.

Normally, below the diaphragm and in the abdominal cavity, there is a functional valve at the junction of the esophagus and the stomach (gastro-esophageal junction). This valve allows saliva and food to travel one way from mouth and esophagus to stomach. When the valve becomes incompetent, stomach contents reflux into the esophagus – resulting in heartburn.

Heartburn is a very common condition. Four to nine percent adults have heartburn daily, and another 10 to 15 percent have heartburn at least once a week. That means about 20 percent of the adults have heartburn on a weekly basis.

Why does the valve become incompetent?

The valve loses its tone. The exact reason for this is not known. It may be associated with some medical condition, obesity or hiatus hernia – a condition in which gastro-esophageal junction slides between the chest and the abdomen through the opening in the diaphragm – a sliding hiatus hernia. Hiatus hernia may or may not be associated with reflux and vice versa.

How is it diagnosed?

Diagnosis is based on classical symptoms of heartburn. Difficulty swallowing food, liquids or even saliva signifies narrowing of the esophagus due to inflammation, scarring or cancer. Barium x-rays have a limited value in the assessment of esophagitis (inflammation of the esophagus) or Barrett’s esophagus. Endoscopy (gastroscopy) and biopsy is the best way to assess the lining of the esophagus for inflammation or pre-malignant Barrett’s changes.

Every person with heartburn does not require gastroscopy. The NEJM editorial says that there is no precise protocol to say when gastroscopy is warranted in patients with heartburn. The usual indication is when heartburn is severe enough to be the main symptom for which medical evaluation sought, and in patient who presents with difficult swallowing.

Heartburn can be prevented by change in life-style: lose weight, change eating habits, avoid bending or straining, sleep with head end of the bed elevated (maximum damage to the esophagus occurs at night), no smoking, no alcohol, and take appropriate medications to neutralize or reduce acid in the stomach. Surgery is also an option in patients with intractable problems or complications of reflux.

Remember, heartburn should not be ignored and must be given respect!

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Asprin and Heart Disease

“Approximately 25 percent of the reduction in the rate of death from coronary artery disease that has occurred during the past 30 years may be explained by the practice of primary prevention,” says Dr. Michael Lauer, of Cleveland Clinic Foundation, in an article in the New England Journal of Medicine (NEJM).

What is primary prevention?

Primary prevention involves a deliberate treatment of a person with established risk factors for heart disease although the person has no clinical symptoms or other evidence of heart disease. The purpose is to prevent cardiac events like heart attack.

What are the risk factors for heart disease which can be target of primary prevention?

There are several of them: high blood pressure, smoking, high cholesterol level, sedentary (much sitting and little exercise) life style, platelet activity (a type of blood cell which can stick together and block coronary arteries) and inflammation.

Family history of heart disease is a risk factor as well but there is not much you can do to change that!

What is the role of aspirin in primary prevention?

Aspirin has both anti-platelet and anti-inflammatory effects. In 1970s, studies suggested regular aspirin use could reduce the risk of heart attack and death from coronary artery disease, says the NEJM article. More recent studies have confirmed this although many aspects of aspirin use are uncertain.

The article’s conclusions are:

-Aspirin use probably reduces the risk of heart attack in men over the age 50 years. It is unclear whether women have the same sort of benefit as men.
-The decision to initiate aspirin therapy should be based on assessment of absolute risk of a heart attack.
-For prevention of heart attack, low doses of aspirin (100 mg per day or less) are adequate. For prevention of stroke, low-dose aspirin is just as effective as high-dose therapy.
-Observational studies have suggested that aspirin may prevent cancer of the colon, esophagus, stomach, and rectum. But this has not been confirmed.
-Aspirin use can cause bleeding. Most common site of major bleeding (bleeding leading to death, transfusion, or surgery) was the gastrointestinal tract. It can cause minor bleeding like nose bleeds and bruising as well.

Aspirin is also called Acetylsalicylic Acid, derivative of salicylic acid that is a mild, non-narcotic pain killer useful in the relief of headache and muscle and joint aches. Aspirin is also effective in reducing fever, inflammation, and swelling and thus has been used for treatment of rheumatoid arthritis, rheumatic fever, and mild infection.

German chemical and pharmaceutical company founded in 1863 by a chemical salesman, Friedrich Bayer (1825-80), and now operating plants in Germany and more than 30 other countries was the first developer and marketer of aspirin (1899), says Encyclopædia Britannica

Aspirin has been with us for over hundred years. It is cheap and universally available. It has many health benefits. But it is not completely safe. So, before you start taking aspirin, talk to your doctor. See if it is safe for you. And don’t forget other risk factors which require your attention. Help your doctor keep you healthy!

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Peanut Allergies in a Nutshell

In the last column, we discussed some important aspects of peanut allergy. Today, we will concentrate on prevention, immediate management and where to find more information on this important subject.

As in the last column, we will use information provided by Dr. Hugh Sampson, paediatrician, Mount Sinai School of Medicine, New York, in his article published in the New England Journal of Medicine.

Sharon Pudwell, a local parent of a child with peanut allergy, has also given me information to share with you.

Dr. Sampson says that children with peanut allergy, their parents and caregivers, must be educated to:

-to avoid accidentally ingesting peanuts
-learn to recognize early signs of an allergic reaction
-learn to give medication as soon as symptoms develop.

Parents and children should check all food labels. They should avoid high-risk situations such as foods served in buffets and ice-cream parlours and unlabeled candies and deserts.

Symptoms of allergic reaction can appear within few minutes to few hours. Pudwell says that some of the early symptoms are: itchy eyes, nose, and face; flushing of face and body; swelling of eyes, face, lips, tongue and throat; hives, vomiting, diarrhoea, wheezing, a feeling of fear and apprehension; weakness and dizziness; inability to breathe and eventually loss of consciousness. The condition may end in shock and death.

Treatment of acute reaction (anaphylaxis) by patient and family members include injection of epinephrine (depending on patient’s history and symptoms) with EpiPen Autoinjector and oral liquid diphenhydramine (an anti-allergic medication). Patient should be transported to hospital emergency immediately. Let emergency physician take over the care. Patients should be observed in the emergency department for at least four hours after they have recovered.

Dr. Sampson says that considerable amount of education material is available from the Food Allergy and Anaphylaxis Network (telephone number, 1-800-929-4040; web site www.foodallergy.org). This web site contains written emergency plan (every allergic child should carry one) and appropriate doses of liquid diphenhydramine and self-injectable epinephrine

Locally, Pudwell had started a support group. She says, “My support group no longer meets. I do not know personally how many people in this area suffer from peanut allergies. I still take an active part in education (in schools) and am available to anyone who would require support”.

She adds, “You can give my name and phone number (527-0997). Here are a few sites I use for up-to-date information: www.peanutallergy.com; www.cadvision.com/allergy; www.anaphylaxis.org. These are all excellent web sites for resources, alerts, food recalls, and discussion boards”.

Pudwell suggests the following rules:
-carry Epi-pen
-wear a medical alert bracelet
-carry a cell phone
-do not ever share foods – eat only foods you have prepared yourself or in a child’s case only food your parents have prepared for you.
-read and re-read labels
-be aware of your surrounding

Pudwell says, “To believe that the world can be free of peanuts is unrealistic, or to single out a child as somehow not quite equal to another because of allergies is unfair. We believe children must learn to live with the knowledge of their allergies, and be taught from a very young age the coping skills they will need for a safe and healthy survival”.

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