Ah, Acid

Why won't it stay where it belongs?

One of the duties of a human stomach is to use acid as a food additive – the acid helps digest food dumped therein. A person with a condition called “achlorhydria”, meaning a lack of stomach hydrochloric acid, has digestive difficulties. He also has problems absorbing nutrients like calcium and iron.

Acid is a useful item on the digestive menu, as long as it does its job inside the stomach and is then properly passed through to the small intestine, where it is neutralized by alkaline intestinal secretions. Meal over, end of story.

But wait! There’s more! Sometimes acid goes the wrong way, back north into the esophagus (gastro-esophageal reflux disease, or GERD), where there is nothing to neutralize it, resulting in pyrosis, or heartburn. This is a very common and usually irksome but not terribly troublesome symptom. If left untended, however, this will in time increase one’s risk for esophageal cancer.

Shortly after baking soda became readily available, someone discovered a dose of it would immediately relieve heartburn, and that became a common remedy whose use persists to this day. Soda works well, but there is an acid rebound afterwards, meaning that ever larger amounts are required to keep heartburn at bay. It also adds to the body’s sodium burden, and can plunge some users into congestive heart failure. This is not a good thing. So Gelusil, an aluminum salt / antacid, was invented.

After Gelusil and its acid-neutralizing relatives, Maalox, Mylanta, Riopan, etc., came the first acid-REDUCING wonder-drug, Tagamet. Followed by Zantac, Pepcid, and others, it was so effective, everyone thought the battle against GERD was officially over, mission accomplished, shut out the lights and go home.

Not so fast, there, buddy. Another family of acid reducing agents came on line in the 1990s, and GERD treatment changed again. Prilosec was the first, and three or four others have followed. These PPIs (for proton pump inhibitors) effectively shut down the stomach’s acid factory. No acid, no heartburn, even if GERD is still happening. For most doctors and their patients, helped along by generous amounts of direct-to-consumer advertising, PPIs have become the first choice remedy for GERD. Now we could shut out the lights and go home, right?

This week, the lights were turned back on, when a study was widely reported which showed prolonged use of PPIs caused osteoporosis and fractures. This is probably due to an adverse effect on calcium absorption. Big surprise. It may be followed by another which shows iron deficiency anemia also happens more often in PPI users.

You just can’t mess around with Mother Nature and expect her not to strike back.

Many cases of GERD can be cured by eating slowly and chewing better, avoiding fatty foods, avoiding the bed when your tummy is full, avoiding caffeine / chocolate, stopping carbonated drinks, reducing alcohol, stopping smoking, and losing weight. That’s so simple, why didn’t we think of it sooner? (Actually, we did think of it sooner. This is advice from the 1960s.) Shape up, eat right, save a bundle of money (PPIs are quite pricey), and maintain strong bones.

Oh, and it’s OK to use a few Tums from time to time. They will suppress the heartburn and give you some extra calcium in the bargain.

(Caveat for anyone not responding to the simple rules – you really need to be scoped and maybe biopsied, and you may need a PPI for the sake of your long-term esophageal health. We’ll take care of the osteoporosis some other way. Additionally, some who have a hiatus, or diaphragmatic, hernia may have GERD which is correctable surgically. Maybe, sort of.)