While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment
As a family physician, I commonly see a patient with a diagnosis of acid reflux, GERD (gastroesophageal reflux disease), esophagitis, or dyspepsia. With these diagnoses, patients report symptoms of upper abdominal upset and burning sensation, vomiting, and difficulty sleeping to name a few. These symptoms can be debilitating and prompt patients to seek relief. Frequently, these people have been taking a proton-pump inhibitor (PPI) medication like Prilosec (Omeprazole). Sometimes, these patients have been taking these medications for many years. If you look at the prescribing information, it will say "for short-term use," sometimes 14 days.
Here is a list of some of these medications: omeprazole (Prilosec), (esomeprazole) (Nexium), dexlansoprazole (Dexilant), pantoprazole (Protonix), lansoprazole (Prevacid), omeprazole plus sodium bicarbonate (Zegerid), and rabeprazole (Aciphex).
In general, PPIs are believed to have few adverse effects. A few minor side effects of short-term PPI use reported include: headache, rash, dizziness, and gastrointestinal symptoms, including nausea, abdominal pain, flatulence, constipation, and diarrhea.
What are the long-term side effects of PPI? Although PPIs seem to have an encouraging safety profile, recent studies regarding the long-term use of PPI medications have noted potential adverse effects, including increased risk of bone fractures, pneumonia, autoimmune disorders, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, food allergies, gut dysbiosis (small intestinal bacterial overgrowth), increased risk of stomach cancer, and dementia.
In general, with any GI symptoms I consider other causes besides GERD, including: stress, psychiatric disease, poor diet, gluten-sensitivity, altered gut micro biome, parasitic infection, intestinal dysmotility, small intestinal bacterial overgrowth (SIBO), and achlorhydria (lack of stomach acid).
Sometimes, hard to tell if the treatment is causing the disease. If patients are placed on PPI medications for inappropriate reasons, then things can go haywire. SIBO can occur if gastric acid, bile, digestive enzymes, and immunoglobulins are not functioning properly. Inadequate gastric secretion and small intestinal dysmotility seem to be the 2 most common factors that predispose individuals to SIBO. Consider prolonged proton pump inhibitor use as the potential cause of this cascade of events.
Adhesions, strictures, diverticuli, immunoglobulin deficiencies, pancreatic insufficiency, and cirrhosis can also predispose to SIBO. Common symptoms of SIBO include: Bloating, flatulence, abdominal pain, diarrhea, and constipation. Extra-intestinal manifestations of SIBO include: Restless leg syndrome, rosacea, anemia, arthralgia, interstitial cystitis, neuropathy, weight loss, chronic pelvic pain, dysuria, dyspareunia, prostatitis.
SIBO can increase leaky gut, which can cause inflammation and immune activation, including mast cell activation (see prior posts about mast cell activation syndrome).
Consider breath testing to diagnose SIBO. If positive for methane, then SIBO likely.
If SIBO is present, you will likely have poor digestion of fats and poor nutrient absorption with deficiency in: Vitamin B12, vitamin A, vitamin D, vitamin E, vitamin K, calcium, magnesium, and iron.
Treatment: Consider carbohydrate and lactose elimination diet if SIBO. Consider low FODMAPS diet (see other post). Use probiotics. Consider a temporary liquid elemental diet in severe cases. Replace vitamins. Consider down-regulating mast cell function with quercetin and resveratrol supplementation.
Consider oregano, thyme, olive leaf, and berberine extracts for their antimicrobial effect.
Antibiotics for SIBO: rifaximin 550 mg 3 times daily x14 days. Second line includes: Bactrim, Cipro, Augmentin, and doxycycline for 10 days. If 2 courses of antibiotics do not improve symptoms, consider other diagnoses.
SIBO is present in 80% of people with irritable bowel syndrome (a very common diagnosis).
Approach to patients with hypochlorhydria (low-stomach acid).
Possibly replacement with Betaine HCL and pepsin helps. Do not institute if patient has active gastritis, esophagitis, or duodenitis. Of course, PPIs will make a low-acid condition worse, not better.
Be wary. If your doctor tells you to take a PPI, this may not be the right choice for you. Be willing to consider other causes. I encourage you to contemplate the root cause of your symptoms that could be treated, instead of covering up the symptoms with a medication that has potential down-stream consequences. As you will note, one of the main treatments for SIBO is carbohydrate elimination. Low-carbohydrate, high-fat diet can be very helpful for GI symptoms. I don't want you think of SIBO as some fancy diagnosis, just do the right thing with your diet and often the rest of your health will fall in line.
I hope this information helps you and your loved ones!
Jason Williams, D.O.