— Richard, Louisiana Diffuse esophageal spasm is a relatively uncommon disorder that results from abnormal movements of the muscles lining the esophagus. The painful pressure mimics the pain of a heart attack, making it important to rule out heart disease, as you have done. Fortunately, there are effective treatments for esophageal spasms, including calcium channel blockers and nitrates. (Coincidentally, these medications are also used to treat angina, a symptom of heart disease.) Some patients note that cold or hot foods, particularly liquids, can exacerbate the spasms. If you notice this, avoid foods and beverages at excessive temperatures. Try keeping a log of when you have the spasms so you can attempt to discern a pattern. Also, speak to your doctor about the medications I mentioned above to see whether they might be appropriate for you. Q2. What are the long-term side effects of taking acid reflux medications (Prevacid, Prilosec, Aciphex, etc.)? The news about long-term effects is good. These medications are called proton pump inhibitors (PPIs) because they block an acid pump in the stomach; besides treating GERD, they are also effective in healing inflammation and ulcers of the stomach and duodenum, the portion of the small intestine into which the contents of the stomach empty. PPIs have been around since the mid-1980s in the United States and have an excellent safety record. The first available PPI agent, omeprazole (Prilosec), has been available over the counter without a prescription for the past few years. When omeprazole was first approved, it carried a warning to use for only eight weeks because of concern at the time about an increased risk of stomach cancer. In fact, this risk was found only in rats given super-high doses over a very long period of time, and the “cancer” these rats developed turned out to be gastric carcinoids, which are usually benign. No increased risk of human cancers has been attributed to PPI agents. The major long-term side effects of PPIs are vitamin B12 deficiency and, much more rarely, iron deficiency. The cells in the stomach that make acid also make a protein called intrinsic factor, which is necessary for the absorption of vitamin B12. Proton pump inhibitors block the release of intrinsic factor, so, over years of use, they can cause some patients to develop vitamin B12 deficiency, a condition that can be corrected with supplements. Proton pump inhibitors have also been linked to a possible increased risk of hip, wrist, and spine fractures, especially in people who take high doses or who use PPIs for a year or longer. In addition, stomach acid helps iron absorption, so using a PPI, which blocks acid, can occasionally lead to iron deficiency. The good news is that the typical Western diet is so rich in iron that a deficiency is very uncommon, but do check your vitamin B12 and iron levels if you feel weak, tired, or short of breath. Vitamin B12 levels should be checked — even if no symptoms develop — after three years on a proton pump inhibitor, and yearly after that. Q3. I read a report that long-term use of Nexium can cause bone loss. What is your advice on the best way to reduce this side effect? Nexium is one of the proton pump inhibitors, a group of medications that block acid production in the stomach. These agents have been on the market for some time and are generally considered safe; the first of these to come to the market, Prilosec, is now available over the counter. Nevertheless, recent studies suggest that proton pump inhibitors can cause bone loss and hip fractures in some patients. Acid is needed in the conversion and utilization of some forms of calcium taken by mouth (such as calcium gluconate); calcium carbonate appears to be absorbed well in the presence or absence of acid. Using proton pump inhibitors can lead to lower calcium absorption and, over time, bone loss. In some patients, this bone loss, also known as osteopenia or osteoporosis, can result in hip fractures. The level of acid suppression usually correlates with the rate of bone loss — the more medication you use, the higher your risk of bone loss. In order to minimize this side effect, I would recommend taking these drugs at the lowest dose possible that will not compromise their beneficial effects. Q4. I have been diagnosed with ulcers in my esophagus for which my doctor prescribed Prilosec. After two doses I began to have an allergic reaction. What can I take for my ulcers that is not in this family of drugs? You may be allergic to the ingredients used to manufacture the Prilosec capsule, rather than to the drug itself or to the class of medications it belongs to (known as proton pump inhibitors, or PPIs). If your allergic reaction was mild, you may want to try another PPI, particularly one that is not in a capsule form, such as Aciphex. However, if you still have an allergic reaction, different types of medications can be used quite effectively. These include histamine receptor blockers (Tagamet, Zantac, Pepcid, Axid) that, like Prilosec, block acid production, or Carafate, a liquid that covers the esophagus and helps the ulcers heal. Talk to your doctor if you want to try one of these medications. Q5. I was recently diagnosed with Barrett’s esophagus. What causes this and is it serious? — Grace, New York Barrett’s esophagus stems from gastroesophageal reflux disease, or GERD, a condition that results from stomach contents washing up into the esophagus. People with Barrett’s esophagus experience a change in the cells lining the lower esophagus because of chronic exposure to stomach acid. Your doctor probably diagnosed Barrett’s esophagus by examining the color of the lining of the esophagus — Barrett’s is characterized by a salmon color rather than the normal pink. The change in color is a sign of a process called metaplasia, the replacement of one cell type with another. People with Barrett’s esophagus do have a greater risk of developing esophageal cancer, which often spreads to lymph nodes and other organs. With that said, the risk of esophageal cancer for someone with Barrett’s esophagus remains small — less than 1 percent a year. Once you’ve been diagnosed, your doctor will most likely prescribe regular endoscopies to check for cell changes (dysplasia) that could indicate cancer. You can expect to have an endoscopy about a year after your initial diagnosis, and every two to three years thereafter if no dysplasia is present. Should your doctor see cellular changes, he will likely recommend more frequent screenings. There are ways to stop or slow the acids in your stomach from reaching your esophagus, so be sure to discuss these lifestyle changes with your doctor.
If you smoke, quit. Stop now and you’ll decrease both stomach acid and your risk of esophageal cancer.Lose weight and keep it off. This will ease pressure on your abdomen, which causes heartburn and acid reflux.Avoid your triggers. Common culprits include alcohol, chocolate, peppermint, garlic, onion, fatty or fried foods, caffeine, and nicotine.Eat often but eat light. When you eat more frequently, you reduce the risk of overeating, which leads to weight gain and heartburn.Hang loose. Avoid garments that constrict your waist or abdomen.Stay awake. Try to remain upright, or only somewhat horizontal, for a few hours after eating before you hit the hay.Put gravity to work. Elevate your head when you sleep by inserting a wedge between your mattress and box spring.
Q6. Is it best to treat and monitor Barrett’s esophagus regularly, or should the dysplasia be removed? — Roseann, New York Barrett’s esophagus is diagnosed when the normal squamous cells lining the bottom of the esophagus change into abnormal cells, often as a result of GERD. This change in cells is known as dysplasia and constitutes a precancerous condition of the esophagus. For this reason, many patients with Barrett’s esophagus undergo screening at regular intervals, though it has not yet been clearly shown that this type of screening necessarily saves lives. Barrett’s esophagus is a very common condition in the United States, but surgery is not necessary unless high-grade (severe) dysplasia is found. Learn more in the Everyday Health GERD Center.
