7.(5-6) Stomach, Esoph, Duoden/GERD/Ulcer/Cancer

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Also has Chapter 6 on peptic ulcer of stomach and duodenum. Scroll down for it. Update 11 May 2021

5. Gastro-Esophageal (G-E) Reflux

“Reflux” causes "heartburn" due to stomach contents going back into lower esophagus. During certain times of life, it gets paid attention to as Gastro-Esophageal Reflux Disease (GERD). It gives mid chest/upper, stomach discomfort that may go to rib, collarbone, shoulder or armpit on either side and also may be felt in upper and mid back, and may give early morning strangling cough when stomach juice gets in windpipe. With aging, almost everyone experiences the symptom. Episode of GERD follows an overfilled stomach and also is attached to certain foods.  Counterintuitively, I have found it is worsened by the c.90-degree sitting position and starts about 30 minutes after eating, and much improved to disappeared by lying down for an hour especially with a drink of water and in worst cases by an Omepral and/or acetaminophen pill. Probably this is because when you lie down your neutral stomach juices dilute the acid reflux in the upper stomach and in lower esophagus.  

   In middle age it tends to worsen and may catch attention, at first making one think heart disease because pain in chest. Time is spent worrying on it and some get surgery. The Barrett’s esophagus, a micropathologic diagnosis of biopsies from GERD esophagitis is often reported and has increased cancer risk. It should not be worried over.

   Watch what you eat to see what foods cause it. If you note a symptom of it, get up and drink a glass of cold water. The Reflux is more bother than danger to life; it has low complication rate. Preventives are smaller meals and avoiding food servings that you note cause it. I actually find that, counter-intuitively, lying completely flat prevents it while sitting up in chair sleepily after eating is the worst for it. Where simple remedies do not work a one-month course of Omepral, the proton pump inhibitor pill, is useful but don't take it indefinitely.
Warning: An analysis of data on German patients, published by the American journal JAMA Neurology, found that the patients who regularly use proton pump inhibitors for long periods of time were 44 percent more likely to develop dementia compared with patients who were not receiving those medications. (But short courses up to a few months should be no problem)
Do not get complicated tests and do not try surgery unless the GERD is connected with a hiatal hernia.

   I notice GERD but it does not worry me. The discomfort is in chest and upper back especially waking from sleep in chair. I note it at times after sandwiches – ham and egg, potato salad and cheeses. Milk seems to cause it too. Rice is a sometime offender. Foods that do not cause symptoms are spaghetti without strong sauces or cooked oatmeal sans milk. Honey is better than sugar. An esophago-gastroscopy is worth getting to allay cancer fears. Basically GERD should be the least of anyone's old age worries

Flash! Here I want to relate a potential life&death event that I experienced, 17 July 2020. As many may know I am an 88-year-old physician who has lived in a flat in Yokohama Japan for the last 20 years. I started the day feeling OK but by late afternoon I was feeling discomfort located around what is called “the solar plexus”, strictly anatomically the subxiphoid area centered about the central part of the lower breast bone. This was accompanied by what was a tendency to swallow air and belch it back up. I felt hungry and guessed these were hunger pangs so went out, bought a McDonald’s plain hamburger on bun with small amount of ketchup and pieces of sliced pickle in the bun. Back at my flat, now about 6 pm, I ate the whole burger. It was about 7 PM when I finished the burger and the discomfort increased to what I call a kind of bursting, very unpleasant feeling still centered around the area and not radiating to shoulders, arms or other parts, and with increased air swallowing and belching and what we doctors call borborygmi (gurgling sounds from upper stomach).  I was aware from my past history that I have suffered from GERD caused by hiatal hernia of stomach into chest but never as severe as the now described pain and always relieved by standing up and food as this was not that.  And I developed a cold sweat and felt a slight panic that I might be in the early stages of acute myocardial infarction (heart attack).  At this point, around 8 PM I actively considered seeking emergency medical care. At near age 88 one should not stay isolated at home with continuing chest/upper abdomen pain and cold sweat. An acute MI could mean sudden death or an acute GI bleed from GERD, or stomach or duodenal ulcer, similarly.  Tripping to nearby Yokohama hospital would take 15 minutes, but, being a stranger in a strange land, I had better hie myself.to my familiarly used hospital, the Jikei Idai Byoin (Medical School University Hospital in Nishi Shinbashi, Tokyo) where they have my records, where my personal physician has contacts, and which is university. But it means a c.90 minute trip on JR and taxi? I could die on the way. But, I snap decided I prefer to die that way. Besides, I am temperamentally born a risk-taker.  So keeping in mind not to forget my insurance, hospital, money cards and bank book, I bade goo’by my flat and walked to the nearby JR Higashi Kanagawa Station.  By this time I am in a full cold sweat and suffering the severe but stable lower chest discomfort, but, at least I’ve made a decision and am on the way to succor albeit an hour’s way. The fare is JY 400.  The 10-stop, 1 hour trip is suffered in silence. At Hamamatsu-cho I exit the lead car, catch a station taxi and in 10 minutes I am paying 980-yen at front door of the Jikei ER. Soaked in cold sweat and with same pain. I register with my hospital and insurance cards and feel relieved. At least I made it to hospital!  Within minutes I’ve had an EKG (Normal heart rate, rhythm and QRST pattern but still does not rule out a very acute MI), had blood sampled for acute MI enzyme markers (In 10 minutes, result, normal Troponin which rules out acute MI within the last 15 minutes and so relieves my anxiety) and had intern check a normal blood pressure, heart rate and hemoglobin/hematocrit And no blood in digital stool sample (rules out acute GI bleed within last 10 minutes) and receive very definite diagnosis of acute esophagoscope-gastritis from gastroesophageal reflux disorder (The famous GERD but w/o bleed) and am tremendously relieved not only mentally but neurophysiologically.(Pain completely gone after quick IV infusion of Proton Pump Inhibitors (PPI, the famed Omeprazole)
   This is an important description for anyone who may suffer an acute episode of chest or upper abdominal severe discomfort because it tells how to bear with it and what decisions to make.
I speculate here that the severity of the GERD attack may have been enhanced due to an early-in-day 100 mg dose of codeine phosphate that I used for pleasure—-from codeine’s anti-peristaltic GI effect. The 100 mg was an unusually high dose for me. From here on I limit its max dose to 80 mg and watch my associated food intake. Although not serious, a GERD attack is no fun and, certainly, ruins one’s day.

6. Peptic Ulcer and Stomach Cancer

Stomach cancer rate is down in USA. Why? 1) Less cigarettes; 2) Potent anti-histamine-2 receptor medication like Zantac or proton-pump inhibitor (PPI) med. like Omepral; and 3) the fiber-optic, laser-lighted, upper GI scope and rapid, earlier diagnosis of stomach lesion with it.

   Stomach disease causes right upper and mid abdominal pains and starts with gastritis due to fecal-oral infection with bacteria Helicobacter pylori (HP; if your stomach tests +, have your MD Rx Amoxicillin 500 mg, 3 times a day for 5 days) also due to excessive use of aspirin or NSAID's. The bacterial gastritis, untreated, aggravated by bad food, medicines, alcohol or cigarettes, and in presence of high acid stomach secretion, leads to chronic gastritis and then to peptic ulcer in stomach and duodenum (and lower esophagus if reflux).

   Preventing stomach and duodenum disease starts as child and with hand-asshole-mouth hygiene: Wash hand! Wash hand! Wash hands! 

   Avoid or limit aspirin (except when taken to lower platelet aggregation against blood coagulation) or related NSAID's, but acetaminophen is OK.

Get upper GI Scopy if you get symptoms. And be sure to get tested for Helicobacter pylori and if test positive get course of antibiotic.

   Complications of peptic ulcer are perforation or hemorrhage, or obstruction from scarred Gastro-Duodenal sphincter. Perforation of stomach or duodenal wall does not need book l’arnin’; the pain is immediate and extreme and even the municipal moron will be banging at emergency door within hour. An Upper GI hemorrhage is another story. When it is massive and sudden, you see red blood in vomit or in bleeding from anus and are carted off to hospital with no delay. But when bleeding is slow, the telltale sign – denied or ignored – is tarry black, bad-smell feces. Taking Pepto Bismol or iron or some vitamins can give black feces that does not smell bad. If you see it, get to emergency room and test for bleeding. I have seen cases that sat at home, days, bleeding out life despite warning sign of black feces.

   An overlooked cause of stomach bleed is the iron tablets (ferrous sulfate) that are often overdosed for persons with anemia. Do not take iron pill on empty stomach and better several-time-a-day low dose than once-a-day high dose pill. Also be sure you need iron pills by checking blood test iron Fe level. When iron med is very important and not tolerated by mouth, it can be given by injection IV or IM.

   Obstruction due to chronic scarring on G-D sphincter from peptic ulcer is late complication. It makes too much, too prolonged stomach fullness after eating and eventually bad vomiting. Diagnosis is easy and treatment is surgical.

   Stomach and esophageal cancer are diseases mostly of smoker and heavy drinker. Gastric ulcer should get biopsy because of the 4% incidence of cancer in gastritis type ulcers.
End of Chapter. To read next now, click 7.7 Hernia/AP/GB/Frenzy/Transfusion