H. pylori dominated the GI news in the 1990s, and despite it disappearing from the front pages, it remains a common and important clinical problem. The dominant recommended initial treatment strategy has been a clarithromycin-based PPI triple therapy, with either amoxicillin or metronidazole as the third drug. This approach was based on clinical studies, ease of use, and tolerability factors. Bismuth-based quadruple therapy (a bismuth agent, metronidazole, tetracycline, and a PPI), despite demonstrating excellent activity, was usually relegated to second-line therapy because of the complexity of the dosing as well as compliance and tolerability issues.
However, duringthe last decade, the widespread use of macrolides in the general population has led to rising resistance to clarithromycin (by 30% or more of H. pylori strains in some areas), and when clarithromycin resistance is present, the efficacy of clarithromycin-containing triple therapy falls from about 80% to 50% or even lower. However, clarithromycin resistance does not affect the efficacy of bismuth-based quadruple therapy, and that efficacy of those regimens remains at about 90% when patients are compliant with the treatment.
So the questions for you to consider are:
1) Do you know what the clarithromycin resistance rate in H. pylori is in your community?
2) What first-line H. pylori treatment regimen do you use?
3) Are you planning to change your H. pylori treatment strategy now that clarithromycin resistance rates are rising?
There are two huge cancer meetings every year — AACR and the annual meeting of the American Society for Clinical Oncology (ASCO). AACR is the meeting dedicated to basic and translational research. ASCO, as the word “clinical” in its name implies, is devoted mainly to clinical research.
Personally, being a translational researcher myself and a surgeon, I tend to prefer the AACR meeting over ASCO, not because ASCO isn’t valuable, but mainly because ASCO tends to be devoted mostly to medical oncology and chemotherapy, which are not what I do as a surgeon. Each meeting draws between 10,000 to 15,000 or even more clinicians and researchers dedicated to the eradication of cancer. Read more »
If you’re from a Western country, there’s a 10-20 percent chance that you suffer from classic symptoms of acid reflux: chronic heartburn and/or acid regurgitation.
But if you don’t have those classic symptoms you may still have acid bubbling up from the stomach into the esophagus, a condition called “gastro-esophageal reflux disease” (GERD). Over the past decade, research has suggested that acid reflux can cause atypical symptoms such as cough, hoarseness, sore throat, asthma, and even chronic sinusitis. GERD can also cause chest pain, especially if the acid causes the muscle in the esophagus to go into spasm.
As an internist and gastroenterologist, I’ve seen patients who have suffered for years with atypical symptoms of GERD get better with treatment. Although I usually prescribe acid-reducing medication, I try to avoid an approach that relies exclusively on “better living through chemistry.” In fact, my goal is to treat the symptoms with life-style adjustments alone if possible. Smoking and obesity both increase acid reflux and must be addressed. I tell my patients to limit alcohol, caffeine, chocolate, peppermint, and fatty foods (I know, basically anything that gives them even an iota of pleasure in life). I also suggest keeping a food diary to try to identify culprits such as tomato-based products or certain spicy foods. If their symptoms resolve then they can try to reintroduce the things they miss the most. Elevating the head of the bed can sometimes help.
The most serious consequence of chronic acid reflux is esophageal cancer. About ten percent of patients with long-standing acid reflux develop changes in the swallowing tube that increase the risk of developing adenocarcinoma, a deadly cancer with a 5-year survival rate of less than fifteen percent. The condition is called “Barrett’s esophagus. “Fortunately, only about one in 200 patients with Barrett’s esophagus develops cancer each year. And over the last year a treatment called “radiofrequency ablation” has been found to be extremely effective in treating Barrett’s esophagus that is starting to show signs that it may turn into cancer.
It’s estimated that almost 15,000 Americans will die from esophageal cancer this year. Fifty years ago, more than 95% of esophageal cancers were “squamous cell” – the kind caused by smoking and excess alcohol use. As smoking has declined, the incidence of squamous cell carcinoma has dropped. But for reasons that are not clear, esophageal adenocarcinoma – the kind linked to acid reflux (and smoking) – has dramatically increased over the past forty years and now accounts for about half the cases of esophageal cancer. From 1975 to 2001 there was a 600 percent rise in esophageal adenocarcinoma. The obesity epidemic may well be playing a role by increasing the number of adults with acid reflux.
Gastroenterologists can diagnose acid reflux by slipping a thin, flexible instrument (endoscope) through the mouth and down the esophagus. It’s a lot easier than it sounds. Patients are usually given sedation and the back of the throat is sprayed with numbing medicine to avoid gagging. There’s no problem breathing because the tube doesn’t go into the breathing tube (the trachea). Biopsies can be taken from the last part of the esophagus to look for microscopic evidence of Barrett’s and inflammation (esophagitis) caused by acid reflux.
There is currently a controversy about who should be endoscopically screened to look for evidence of Barrett’s esophagus. Only a fraction of the millions of patients with chronic reflux will ever develop Barrett’s. And many patients with Barrett’s have no symptoms at all. In a study in Sweden, 1.6% of the population had Barrett’s but only about 40% had heartburn. And only about half of esophageal adenocarcinoma is estimated to be a result of reflux.
The American College of Gastroenterology recommends against screening the entire population but says it may be appropriate in certain populations at higher risk – such as Caucasian males over 50 with longstanding heartburn. That would be me. So for this week’s episode of CBS Doc Dot Com, I underwent an upper endoscopy, explained and performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at New York-Presbyterian Hospital/Weill Cornell Medical Center. For more information about the Jay Monahan Center, click here.
For information about GERD from the American Society for Gastrointestinal Endoscopy, click here.
Have you ever been seated next to a screaming infant in an airplane? If so, you know that even short flights can feel like an eternity. But the question is: why is the baby so miserable? Is there something that can be done to ease their discomfort?
According to pediatric gastroenterologist Dr. Bryan Vartabedian, the answer is a resounding “Yes!” In his new book, Colic Solved Dr. Vartabedian (or “Doctor_V” as he is known on Twitter) describes why unexplained fussiness may often be caused by gastroesophageal reflux disease. Doctor V explains that “colic” is an old-fashioned term to describe the behavior of uncomfortable babies. Colic is not a medical diagnosis anymore than “crying” is… and fortunately the underlying cause of “colic” has been discovered so that it can also be treated.
I met Doctor V at a conference in Albuquerque, New Mexico a couple of months ago. Before our introduction I had no idea that he spent all of his clinical time examining and treating screaming babies – but once that fact was revealed, I understood immediately that he was the right guy for the job. Doctor V is a tolerant, affable man with a tremendous sense of humor and a voice made for radio. He is not easily flustered and has a genuine curiosity about others and their life stories. In fact, there’s something soothing about Doctor V – something that makes you feel that everything’s going to be ok.
And so it’s no surprise that Colic Solved is a written expression of Doctor V’s winsome personality. Every chapter is filled with empathy and reassurance, yet with a clear path forward for teasing out the real cause of a baby’s misery. In most cases, “colic” is actually caused by milk protein allergy or infant reflux (a painful burning sensation caused by regurgitating stomach acid). Doctor V carefully explains how to tell the difference, and what to do about it. Interspersed are amusing vignettes called “Tales From The Crib” in which parents with difficult-to-soothe babies navigate their way towards a resolution.
But best of all, Doctor V does not hesitate to do some good old fashioned myth-busting when it comes to exaggerated claims not based on scientific evidence. Infant formula makers, baby bottle makers, and baby product manufacturers are notorious enablers of magical thinking – moms and dads purchase all kinds of products in a desperate attempt to soothe their babies. Unfortunately, most of these solutions do not treat the root cause of the problem – though businesses thrive on colic cures for desperate parents.
Here’s an excerpt of Doctor V’s exposé of a common soy formula myth (p. 117):
Soy Formula – Do You Feel Lucky?
One of the first impulses for parents with a screaming baby is to reach for soy formula. It sounds all natural and easy to digest. But the role of soy formula in the milk-allergic baby is very misunderstood…
The real problem with soy formula comes with the belief that it’s a reasonable cure for the allergic baby. But up to 50% of babies who are allergic to cow’s milk will react to soy protein in a similar way, so if you or your pediatrician chooses to treat your allergic baby with soy formula, you should consider it a gamble…
Colic Solved is a gem of a book. It’s witty, wise, and well written – a must-read for any parent of a chronically fussy baby. I also think that pediatricians and family physicians should strongly consider prescribing this book to parents of unhappy infants. There’s probably no better way to solve colic once and for all.
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