Questions and answers about GORD and Barrett's oesophagus

In 2008 I was diagnosed with a hiatal hernia, 9cm section Barrett's oesophagus, and, above that, severe oesophageal ulceration. I also had mild bronchiectasis which can sometimes be caused by gastro oesophageal reflux disease (GORD) due to inhalation of the refluxate.

I suddenly became interested in health matters and have discovered a lot about GORD, Barrett's and the PPIs used to control reflux. This page is essentially a summary of information I have learnt.

I am not medically trained so these facts must not considered as medical advice. However it has become clear to me that a lot of doctors know very little about the drugs they prescribe and if their advice is inconsistent with the facts presented herein, you will better know what questions to ask them to clarify their reasons!


Stomach acid


Control of stomach acid secretion, both triggering it on and triggering it off are extremely complex feedback loops involving the brain and other organs. Acid production is not simply determined by the presence of food. The complexity of this process is probably why acid suppression medications can be so hit and miss for many people.

Bile


Can PPIs affect Bile

Yes. Moreover there is some very convincing evidence that long-term PPI usage can actually damage your gall-bladder. So beware!

See the list of references on gall-bladder.


How can I tell whether bile or acid is causing my symptoms?

Difficult: the symptoms for most, in most people seem to be identical.

Acid reflux symptoms are likely tp be rapidly quenched by a drink of sodium bicabonate - about 1/4 teasoop in a glass of water is usually effective. It does absolutely nothing for bile!

Sodium bicabonate - baking soda - is a harmless chemical and a stronger dose is unlikely to harm. Excess sodium bicarbonate over a period could possibly trigger acid release as the body tries to compensate and this might eventually cause blood alkalinity. Also of course it's not helpful to a low sodium diet, but for the average person it's a lot less harmful that PPIs!


Omeprazole and other drugs

  • Side effects of PPIs
  • PPIs are generally considered relatively safe drugs with few side effects. At least that's the medical opinion. Users have different opinions! The side effects of PPIs may be divided into two sorts:

    Side effects of PPIs due to reduced stomach acidity.

    Diarrhoea.
    If the acid is reduced the normal gut flora will change. This will have knock-on effects on the whole digestion. Diarrhoea is quite likely. It is possible that pro-biotic yoghourts may be useful.

    If diarrhoea persists, medical advice should be sought as some gut infections can be harmful.

    Infection
    A major function of the stomach acid is to prevent bacteria entering the body via the stomach: there are few harmful bacteria which can survive the normal acidity. It follows then that a person with reduced acid may be more liable to illnesses such as food-poisoning.
    Broken bones
    Hydrochloric acid, the normal acid in the stomach, is instrumental in the absorption of calcium from the food. With reduced acid, calcium and other minerals may be poorly absorbed. This can lead to long-term bone weaknesses and fracture. Probably unlikely side effects if you eat a good diet, but a diet with acids such as fruit juices and vinegar might me helpful. Lots of fruit and salads with vinaigrette dressing!
    Tiredness
    As well as reduced calcium intake, iron intake may also be reduced. This can lead to anaemia and consequent tiredness.
    Bile reflux into the stomach.
    Reducing acid breaks a fundamental hormonal feedback loop. Included in this loop is the bile production mechanism. I have described the bile reflux mechanism elsewhere. Also, if the gall-bladder is affected by the PPI then bile release could be erratic, exacerbating stomach bile.

    Side effects of PPIs directly due to the drug.

    These are less likely to predict and are likely to be more variable. However reducing the amount taken of any drug is likely to reduce the side effects, so you should consider taking more frequent, smaller doses.

    One major side effect (which is generally not admitted by the profession) is that PPIs, in most people, affect the gall-bladder (see Gall bladder and PPI usage, causing cholestasis (slow bile release). Poor gall-bladder function can cause effects such as nausea, abdominal pain, vomiting etc. so these may be experienced as a side-effect of PPI usage.

  • Different makes of PPI
  • Most makes of PPIs are enteric-coated granules in a gelatine outer capsule, but but all, so this list may be helpful if you wish to try smaller doses.
  • Q - What is the minimum effective dose of Omeprazole?
  • Minimum effective doses of most drugs do not seem to be published, researched or even known! Drug companies are more interested in selling the maximum safe dose ad safety is a matter of opinion. So minimum effective dose is not generally known! To a layman the concept of minimum effective dose seems fundamental and common-sense. Not so, apparently to the drug trade in general.

    I found that I was almost certainly developing tolerance to PPIs after about 3 years: if so the minimum effective dose will also depend on how long you have been on the drug! There is a blood concentration level below which the drug is ineffective.

    Another page on this site deals with how I experimented to find the minimum effective dose of Omeprazole - or at least a very low effective dose!

    Age affects the dose you need.

  • Q - What is meant by half-life?
  • Half life is, generally, the period after which half of the drug in the body has been removed or metabolised or otherwise employed. PPIs are removed from the blood by the liver. How fast it does this depends on the level of the drug in your blood.

    Some time after you take a dose of a drug it will all have been absorbed from your gut and the blood level will be at a maximum. However the body tries to eliminate this 'foreign substance and the rate at which it is removed depends on the concentration in your blood. So if the half life is 2 hours, then, two hours after this maximum blood level, the blood level will be halved. Two hours later it will be halved again (so 1/4 of the peak). Two hours later it will be again halved - so 1/8th its peak level. It follows that a drug with a short half life should be taken frequently and in small doses. Many antibiotics are indeed taken in this way.

    PPIs have very short half-life! A paper from the US states it to be 1/2 to 1 hour. My own experiments and experience say it is a bit more than 2 hours (but this is the subjective half-life, see below). So if maximum level is reached 3 hours after ingestion then a dose intended to last 12 hours will have halved 4 times so blood levels will have reduced to ½ x ½ x ½ x ½ or 1/16th of their peak level. If that low level is still effective the 12 hourly dose resulted in a 16 times overdose at the peak level.

    The picture is complicated because, as well as the liver clearing the drug, some of it is absorbed properly by the stomach cells that secrete acid. Here is does its work, and there are half life involved in the way these cells can recover and be replaced: that half life is around 50 hours! There is a useful review article on PPIs listed in the links section.

    5 different half-lives. Subsequently to writing the above, I learn more. So far I have located 5 different half-life effects:

    1. Liver clearance half life
      This is the dominant factor and is the main reason why I find 'little and often' to be the theoretical best dosage. It is this that is quoted to be 1/2 to 1 hour.
    2. Proton pump activation half life
      At any one time in a normal stomach parietal cell (the cells that produce acid) some of the proton pumps are dormant and some are active. There is a half-life associated with the process of 'reviving' dormant pumps. I suspect this may be linked in with the normal acidity control loops, so dormant pumps may be awoken as demand increases.
    3. Proton pump replacement
      Apparently proton pumps within a cell can be replaced. There is a half life associated with this.
    4. Cell replacement
      All cells die and are replaced at a rate. A half life here would be the time for half the cells to die and be replaced.
    5. Subjective half-life
      This is the time it will take for you to start noticing the increase in acidity as all of the various half-lives work. It was this I measured at around 2 hours.
    All of the above effects are probably age dependant, so will vary from person to person.
  • Q - Does my age affect the PPI dosage I need?
  • There are many factors affecting the uptake of the PPI by the parietal cells (these are the cells in the stomach that produce acid). Age is one factor - it affects virtually all metabolic processes! The older you are, then the less PPI you are likely to need. Age presumably also affect how well your liver metabolises the drug in your blood - the better the liver's metabolism, the more drug you will need to take.

  • How often should I take PPIs?
  • Your doctor will have prescribed one or two doses per day. Possibly of 40mg each.

    There are a large number of factors involved in optimising dosage, so standard prescriptions are a compromise and are based on two assumptions:

    1. PPIs are safe drugs with few side effects.
    2. You, the patient, are incapable of remembering to take pills at intervals more frequent that twice daily.

    Both assumptions may be wrong in your case! If so - read on!

    A high dose, such as 40mG, results in a high level of the drug in your blood serum. That high level is metabolised quickly by the liver. See Half-life: what does it mean?, above.

    However the effectiveness of PPIs is controlled not by the peak serum level but by the 'area under the serum concentration-time curve'. If you were to measure the serum level and draw a graph showing how the serum level reduced over time - that is the 'serum concentration-time curve'.

    If your daily dose is 40mG then this area will be higher if you take the 40mg as two 20mg doses than as a single dose. It will be higher again if you were to take it as 4 times 10mg. However, the peak level will be halved by the 20mg doses and quartered by the 10mg doses. It seems certain that any side effects you may have are caused by the peak level - not by the 'area'.

    So if you are having trouble with PPIs you can minimise this by taking little and often. 3 or 4 small doses is going to be far more effective than one or two large doses. Your exact dose will vary with your age and other circumstances but you can minimise the amount you need by small, frequent doses.

  • How can I wean myself off PPIs?
  • My own experiences suggest that there is little point in gradual reduction. Cold turkey is the answer.

    It is widely accepted that stopping PPI usage causes rebound acidity. My own experiences suggest the rebound is not acid but bile. Certainly when I stopped, I had intermittent bouts (lasting up to 100 days after stopping PPI usage) of extremely strong nocturnal bile regurgitation. Very unpleasant: bile is far more unpleasant than acid and antacids don't affect it - indeed theory says they could make it worse. See my separate article on bile.

    There is very strong evidence that PPIs can actually cause gallbladder damage: if so then my bile attacks were probably my gallbladder recovering from such damage. See references on gallbladder.

    With this evidence, I believe the sooner you stop PP usage anfd go through the suffering, the better.


    Barrett's Oesophagus

    Barrett's Oesophagus


    Foods


    Cancer