Posts

deer tickWhen Lyme Disease Doesn’t Really Go Away

Ticks are evil.  Deer ticks are even worse: little dots of evil, the size of a freckle.  They spread Lyme disease, and what can happen next sounds like a horror movie. 

But first, the ticks:  They are the minuscule vectors that transmit Lyme disease.  But really what they transmit are corkscrew-shaped bacteria called spirochetes. (Their official name is Borrelia burgdorferia; the disease is also known as Lyme borreliosis.)  Spirochetes are real lowlifes in the disease world; another devastating disease they cause is syphilis. Although deer get the blame for the epidemic of Lyme disease that has hit the East Coast particularly hard, they’re just a truck stop for the ticks; a place to grab a quick meal.  “Deer are immune to Lyme disease, but they are an important food source for the ticks that transmit it,” says John Aucott, M.D., an infectious diseases specialist and renowned expert on Lyme Disease.  (In case you’re wondering, the real culprits for transmitting these nasty spirochetes are rodents.) 

Aucott is the founding physician of the Lyme Disease Clinical Research Center at Johns Hopkins, and I interviewed him recently for Breakthrough, the magazine for the Johns Hopkins Center for Innovative Medicine. 

Now, let’s say you’ve been bitten by a deer tick.  Most likely, you never noticed it.  You may not even know you’ve been bitten unless you happen to see a telltale, bullseye-shaped rash, called Erythemia migrans — which may or may not show up after the tick sucks your blood and in return gives you the gift that keeps on giving.  You may not get sick right away, either.  If you do, you might mistake what’s happening as the flu.  With symptoms like a headache, low-grade fever and chills, fatigue, swollen glands, a headache, achiness, and a stiff neck, who could blame you?  If you’re lucky, you take antibiotics, and you get better.

If you’re not lucky, you may or may not take antibiotics, you may or may not feel better, but you won’t truly be better.  Instead, the disease will get worse as the spirochetes burrow further into your body.  “Lyme disease is a heck of a lot more complicated than many people realize because it’s got a lot of variables,” says Aucott.  “Like syphilis, it’s got multiple stages; so there’s early Lyme disease, the period within weeks after the tick bite.  That’s primarily a skin infection with the rash.  Then in the two- to six-week range, the spirochete disseminates and the illness changes forms,” as the infection moves outward from the bite; these are the flulike symptoms.  “In some people, the disseminated bacteria end up in organs like the heart, or in the nervous system — so the symptoms could look like heart trouble or meningitis.  It’s kind of a moving target with all these different manifestations, depending on how far the disease has progressed.”

Basically, at every stage, even the rash, Lyme disease has the potential to be misdiagnosed; especially if nobody connects what’s happening to the bite of a pencil-point-sized tick.  “Then in the third stage, which may be six months or even years later, you can get arthritis,” says Aucott.  “So you have all these seemingly disparate illnesses that don’t appear to be related, but they’re all due to the different phases of the bacteria.”  Treatment varies, depending on how widely the infection has spread.  “The earlier you treat it, the easier it is to treat.  If you catch it early with the rash, which is what you want to do, it’s much easier to treat than if it’s already disseminated and the patient has had heart or nervous system involvement or joint problems.  It gets harder and harder to treat.”  But the good news is that it is still treatable, and people can be helped even years after the tick bite. 

With Lyme disease, the big question is, “Is it really gone?” 

When symptoms improve, sometimes all the spirochetes have been killed, but not always.  Instead, what’s happening may be the disease equivalent of that deceptive calm at the end of a creepy movie; just when you think it’s safe to go back in the water, it’s not.  Worse, Lyme disease can seem to shape-shift, to present with a whole new constellation of symptoms.

Eight years ago, Aucott, along with Antony Rosen, M.D., head of the Division of Rheumatology, and immunologist Mark Soloski, Ph.D., officially started a clinical research program.  The focus of Aucott’s research is “this whole phenomenon we call post-treatment Lyme disease syndrome” (PTLDS).  “Patients call it chronic Lyme disease, but we’ve tried to get away from that,” because it’s not entirely accurate.  “It’s a distinct part of Lyme disease that happens in a subset of patients who, when treated with antibiotics, don’t fully recover their health.  That’s the controversial part of Lyme disease because it’s much harder to get a handle on.” 

For example, some of the key symptoms — fatigue, pain, and inability to think clearly, or other cognitive issues — are not-very-specific pegs that could fit the description of many illnesses.  “Some people think it’s really nebulous,” Aucott adds, “and to some extent, they’re right.  Because there is not real blood test for PTLDS.  Patients know they aren’t getting better, but until there’s a blood test to confirm that you have PTLDS, it’s going to be very hard to separate those symptoms from those of other syndromes like fibromyalgia or chronic fatigue.”

Aucott and Soloski are actively looking for biomarkers — telltale molecular signs that say, “this person still has Lyme disease.”  Right now, there’s a test that can show that someone has antibodies to Lyme disease, but that’s about all it shows.  “The test shows exposure, and exposure is not the same as active infection,” says Aucott.  “For instance, I have antibodies to chicken pox because I had it when I was a kid, but it doesn’t mean I have chicken pox today.  Those antibodies have a memory, and they stay in your system for years or decades.  But the presence of antibodies doesn’t mean someone is actively sick from the infection; it just means your immune system has been exposed to it sometime in the past.” 

Another issue:  Even if the antibodies show up, it doesn’t necessarily mean that someone’s fatigue is due to Lyme disease.  It could be something else.  Still other issues:  The antibodies can sometimes go away.  “It’s not predictable what they’re going to do.”  Also:  “You can get it more than once, because there are different strains.  You’re not protected; I’ve had patients who have gotten it two or three times.”

What’s being done

Aucott and Soloski are studying patients using proteomics — the study of ultra-specific proteins, which are like footprints in the blood.  “What makes our study very unique is that we have the patients at the time of their initial diagnosis when they have the rash before they even get antibiotics,” says Aucott.  “Then we follow them for seven visits,” taking blood samples each time. “So we can follow these proteomic shifts” the trail of the footprints — “just like you would in a patient who’s having a heart attack, except our time scale isn’t a matter of hours, but many months.”  The goal is to find changes over time that can lead to a test that says, “This person still has active Lyme disease,” or “the disease is not active in this person.”

The real Holy Grail, Aucott continues, “would be if we can find a pattern that identifies people who are destined not to recover completely, the people who are going to need further intervention because they’re destined to go on to PTLDS.  In medicine, we like to treat people, but then we also like to repeat their test and show that they’re cured.  Like in cancer, you repeat the CT scan, or in a heart attack, you repeat the EKG.  But in Lyme disease, there’s nothing to repeat, nothing to show that the person has recovered.”

Still other things to think about:  When someone with Lyme disease doesn’t get better, is it because the antibiotics didn’t kill all the bacteria and a few remain dormant?  “That’s one hypothesis.  Or maybe the infection triggered an autoimmune disease; there’s good precedent for that, as in rheumatoid arthritis.  Or maybe it’s a combination of the two; maybe most of the infection is gone, but that little bit triggers an ongoing inflammation.”

©Janet Farrar Worthington

Mr. Rogers' Neighborhood

Gene J. Puskar/Associated Press

If you’re old enough to remember Mr. Rogers, you might remember him singing the happy little song, “So, who are the people in your neighborhood, in your neighborhood, in your neighborhood… they’re the people that you meet when you’re walking down the street.  They’re the people that you meet each day.”

This isn’t Mr. Rogers’ neighborhood.  It’s a lot smaller, but there are some interesting characters here.  They are bacteria, also called gut flora, or microflora.

The microflora in the gut are way more important than anyone realized even a few years ago.  This microbiome is made up of communities of bacteria and other organisms.  Tiny changes here can have big effects — not only on our digestive tract, but on our emotions.

Cynthia Sears, M.D., professor of medicine at Johns Hopkins Medical Institutions, is the director of the Scientific Advisory Board of the new Johns Hopkins Food, Body & Mind Center.  (I wrote about some of the research going on at this center in a recent post.)  In addition to finding links between diet and disease, scientists at the Center, particularly Sears, are studying the role of good and bad bacteria in making us sick and keeping us healthy.

Sears has focused on the many interactions between the gut’s microflora – the little ecosystems of bacteria that live and die down there in without our ever knowing about it – and our health.  I recently interviewed her for Breakthrough, the magazine for the Johns Hopkins Center for Innovative Medicine.  Rapidly expanding evidence, she told me, suggests “that the complex communities that we carry with us, which are on every surface of the body, are essential to health.  But they’re also associated with disease” — both right there in the gut, and distantly.  “They influence liver function, the function of the deep tissues, the enteric nervous system.”  They may also contribute to heart disease, pancreatic conditions, and be linked to our mood and to psychiatric disorders, as well as our weight.  “This concept is amazing,” she says, “particularly the idea that they can influence our mood and how we function in life.”

So, imagine that you have depression, and a doctor has put you on an antidepressant.  And it’s not really helping that much.  Then imagine that a doctor tells you, “the problem could be in your gut.”  This discussion is still pretty new, Sears says, but “our hope is that we will be able to identify the bacteria that produce the right metabolites, the ones that make you feel better,” to change how the microbiome functions.  “So if the microbiome has bad molecules, that we could modify it or treat it in such a way that you get good molecules and change the balance.”

Good bacteria

Photo Credit: sahilsajjad via Compfight cc

I asked her if this might one day eliminate the need for antidepressants.  Probably not, Sears says.  “But there are a lot of people who probably don’t fit into classic psychiatric criteria, who don’t feel well.  So this idea that we can use food and possibly ‘good’ bacteria to modify function and make someone feel better, and help turn someone’s life around, is very intriguing.”

Fermented Foods and Probiotics

Is there anything you can do to help clean up the neighborhood of bacteria in your gut?  Well, yes:  You can eat fermented foods, which contain probiotics, or you can take supplemental probiotics.  The problem with probiotics is that they are not regulated as drugs by the FDA, and there is a lot of variability in quality and effectiveness.  Similarly, there is a surprising lack of definitive, scientific journal-published research absolutely proving that fermented foods are helpful to your health.  However, that said, there is a lot of anecdotal evidence that they are.  The fermented items listed below, eaten in moderation, are not harmful to your health.  You may want to give them a shot for a couple of weeks, and see if you feel better with them in your diet.

Sauerkraut.  It’s fermented, hip, it’s happenin’ — check out the gourmet varieties (like Wildbrine’s Arame Ginger) of sauerkraut in the refrigerated section at upscale grocery stores — and it’s been around since the 4th century B.C.  First of all, it’s cabbage, and cabbage is already good for you, just raw out of the garden.  It’s in the family of cruciferous vegetables, along with broccoli and cauliflower, which have long been shown to help prevent cancer.  But the fermentation process brings some new chemicals to the table, including: isothiocyanates, which counteract carcinogens and help the body remove them; glucosinolates, which activate the body’s anti-oxidants; and flavenoids, which help protect artery walls.  Sauerkraut has few calories.  However, if you eat too much of it, it can cause diarrhea.  Again, moderation in all things.

Kombucha.  Fermented black tea.  Again, we’re starting with something that is already good for you; tea is rich in antioxidants.  Fermented black tea delivers a load of probiotics to your gut.  In addition to aiding digestion, these beneficial bacteria boost the immune system and can relieve irritable bowel symptoms, yeast infections, and other problems.  In one study, rats given kombucha had higher levels of “good” HDL cholesterol, a finding linked to a lower risk of cardiovascular trouble.   FloraStor, a commercial probiotic that’s used to treat C. difficile colitis, was isolated from kombucha.  A study from India found that a form of kombucha was just as effective as the drug, omeprazole (Prilosec), in healing stomach ulcers.  (Note: If you have an ulcer, I wouldn’t chuck Prilosec and start drinking kombucha.  For one thing, the kind you get might not have the kind of bacteria these scientists studied; also, how much would you need to be drinking every day, and for how long?  Ideally, as fermented foods become more popular, they will be better studied and their benefits will become a lot more clear.)

file5321333011701Yogurt.  Look for the words, “Live and active cultures.”  These are probiotics, and besides increasing the number of good bacteria in your gut, they can help reduce symptoms of irritable bowel syndrome, and also can help improve symptoms of inflammatory bowel diseases, such as Crohn’s and ulcerative colitis.  Greek yogurt has more protein than traditional yogurt; it takes longer to digest and can help you feel full longer — which, in turn, can reduce the need for snacks between meals, so as a bonus, it may help you lose weight.

 

 

©Janet Farrar Worthington

This isn’t what I intended to write about; in fact, I’m in the middle of a series on the gut.  However, the series has been derailed briefly, because I have been derailed, I hope briefly, by one mother of a headache. 

viseThree times in my life, I’ve been in so much pain that I have not even felt like a human.  One was during the birth of my second child; he was turned around in such a way that there was tremendous pressure on my spine, and I couldn’t even talk.  Seriously, I was reduced to moaning sounds like an animal.  But this is a men’s health website, so I’ll spare you that story and move right to the other two times, which have been migraines.  Actually, the migraine I’m going to talk about is the one I’m getting over as we speak.

There are people who suffer from migraines and spend more days in pain than not.  I am not one of those people, and usually, if I get a migraine, it goes away after a while and has an attributable cause.  There are a bunch of known dietary triggers for migraines, including chocolate, aged cheeses, soy, and vinegar; caffeine; alcohol (red wine, beer, sherry and vermouth); food additives like MSG (monosodium glutamate) and hydrolyzed vegetable protein (HPV); nitrates (preservatives) found in hot dogs, pepperoni, jerky, lunch meats, and other smoked or preserved foods; tannins, found in tea, red wine (again with the red wine!), cider, and red-skinned fruits like apples and pears; sulfites (this is another preservative), found in dried fruits and red and white wine; the artificial sweetener, aspartame (NutraSweet and Equal). 

This is not a complete list, but it goes along with what we’ve been talking about recently, that sometimes food can make you sick.  Here’s something to think about: If you think something in your diet is making you sick, try giving it up for three weeks.   Just one category at a time (like, dairy foods) – otherwise, you won’t know which thing you gave up was making you feel bad.  We will talk more about this in the future, I just wanted to get this in there. 

But it’s not always diet.  There are numerous other triggers for migraines, and I have three of them:  stress, fatigue, and dehydration.  All three of them kicked in and that’s what started my recent 12-day trip to hell.  So what I want to talk to you today is in the headache category, and it’s certainly a migraine, but to a certain degree, it was also self-inflicted and needlessly prolonged.  It started for me on Mother’s Day weekend; our choir at church did three back-to-back concerts that might not have fazed a hardier person, but they knocked me on my rear end.  So that was the precipitating factor.  But what I did next escalated it to the extent that on the worst day, yesterday, I was seriously considering going to the emergency room.   

The first thing I did, some of you men reading this may well identify with:  I denied it.  I thought, “This is not a migraine.”  I had too much to do to deal with a migraine.  I had to keep going.  So I started taking Advil.  This is by no means any indictment of Advil; it is a fine product.  I just overused it.  I started taking two, and then four a day.  The headache would go away, and I would be able to get some work done, plug away at my various writing projects, chauffeur my youngest child, walk the dogs, do the housework, etc.  Then it would come back. 

headacheI failed to make the connection that this was one prolonged event. 

In fact, I even joked about my daily headache, and I thought if I could just make it to the weekend, or to bedtime, or a break in the on-the-run schedule, surely it would get better.  By Day 10, I was up to six Advils a day, and the headaches kept coming back and were getting worse.   I now know that this was a series of rebound headaches.  Other symptoms of rebound headaches can include irritability, difficulty concentrating, restlessness, nausea, memory problems, and lack of energy.  In my defense, you don’t do your best thinking when you’re having a migraine, so maybe that’s why it took me so long to figure it out. 

In my case, the headache was a vascular one; severe pain on my right temple and a big-ass pulse that throbbed visibly (in fact, my right temple freakily stuck out more than my left). 

What I should have done.

I should have realized that this was a migraine and taken actual migraine medicine to knock it out immediately.  I actually have a prescription for Frova, a very effective drug that probably would have worked better, had I taken it sooner.  But the thing had gotten so out of hand, it was hard to rein it back in.  I took one on the evening of Day 10, and it got better.  Day 11, it came back.  I took another one.  It helped, but didn’t stop it.   By this point, I had wised up to the ibuprofen (Advil), so I tried acetaminophen (Tylenol) plus caffeine.  This helped a little, but not enough.

Then, my wonderful daughter stepped in.  She has done a lot of research on natural remedies, and I want to share some of these with you.  Now, before you make some judgment and say, “Here we go, one of these crunchy granola types, she’s going to tell me to peel some willow bark and boil it.”  Not at all, and shame on you!

What I am saying is, “Here are some more weapons for your arsenal.  Try any and all of them, because the headache is your enemy, and you need to confuse it, so you can disarm it.”

All of these treatments did something very important:  They diverted blood flow away from the headache. 

This strategy is your new best friend.  This is what you must do, whether it’s through prescription remedies, over-the-counter items, or complementary medicine (natural remedies).  I think it’s a good idea never to rely on one treatment to take care of you and make it all better.  There’s something to be said for the kitchen-sink approach:

Go after it with all you’ve got. 

The first thing that helped:  Peppermint oil.  Rubbed on the temples, but I dabbed it all over my face.  (Note:  Peppermint oil can be irritating to the skin, so I probably shouldn’t have put it all over my face.  Now it looks like my face is chapped in various places, but the pain is better, so I don’t even care.)  Peppermint oil contains menthol.  Menthol cools.  It counteracted the heat and temporarily dulled the pain in my temple.  I blessed it; I was so grateful to that peppermint oil. 

Thinking the menthol was a good thing, I got out some Icy Hot and put it all over my back.  Icy Hot has menthol and menthol salicylate, so it cools the skin and also causes a warming sensation that relaxes the body.  Basically, it distracts your brain from the pain.  If I’d had any capsaicin (an ingredient in chili peppers, this warms the body and relieves pain, too), I would have put that on, as well.  Not on my head, but on my back or shoulder. Again, just an effort to divert the blood flow and confuse the pain sensors.

The most helpful thing:  15 minutes soaking my feet in very hot water with Epsom salts.  This had several benefits.  One, Epsom salts contain two helpful elements: magnesium and sulfate (not to be confused with sulfites, the food preservative mentioned above).  Deficiencies in both of these can cause headaches.  Magnesium is hard to absorb through the stomach, mainly because it’s also a laxative.  But you can absorb it just fine through the skin in an Epsom salt footbath.  The salts help draw out toxins from the body, too.  But the biggest thing is, if it’s just as hot as you can stand it, this diverts blood flow from the headache in a big way.  A hot shower helps do this, too; it would also have helped if I had put my hands in the hot Epsom salt water instead of my feet.  (Have you ever had a migraine and noticed that your hands are cold?  That’s because all the blood flow is in your head!)  The effect there is like taking the oxygen away from a fire; without fuel, it can’t keep burning. 

Through this combination of remedies, I have turned the corner on the headache.  I did not go to the ER, I did not call my doctor and get another high-powered medicine. Maybe I should have, but again, when there’s something wrong with your head, you can’t think too well. 

What have I learned? 

tablet wrapperDo I think you shouldn’t use over-the-counter headache remedies?  Of course not.  Acetaminophen is good, particularly with caffeine and/or aspirin added.  It is odd that caffeine can trigger a migraine and is also used to treat one, but there you go.  Ibuprofen is good.  Prescription drugs are good.  Natural remedies are good.  But I truly believe you have to mix it up. 

Have you ever watched a football game when the quarterback keeps doing the same play over and over – even though it’s not working?  And you’re yelling at the TV, “Mix it up, moron!” Any pain reliever can cause a rebound headache if you use too much of it. This includes migraine medications, and especially opiates (Tylenol with Codeine, for example).

If you have more than two headaches a week, if you need to take pain medication for your headache more than twice a week, if the recommended dose doesn’t get it, or if your headaches are getting worse or lasting longer, go see a doctor.  But also remember:  You may be having rebound headaches.  Mix up your treatment approach, and try to limit the fuel for the fire by diverting the blood flow.  Confuse the enemy.

P.S.  My mother-in-law, who has suffered from terrible migraines for years, meditates to get her body to slow down, which helps whatever medicine she’s using work better.  Tension definitely plays a role in many headaches, so medication and yoga may be something for you to explore, as well.

©Janet Farrar Worthington

gut ache

Ever had a gut feeling?  Felt butterflies in your stomach?  Maybe gotten a little crampy or needed to make an emergency trip to the bathroom during times of stress?

Now, let’s look at this from the other end, so to speak:  Maybe you’ve been feeling anxious or depressed.   Maybe you feel bad, and you don’t know why.  Maybe something in your diet is making you feel this way.

Maybe what you eat is making you sick.

There is an intimate, intricate link between the brain and the gut that scientists are just beginning to understand.  Questions are being asked and investigated that, frankly, nobody thought of even a few years ago, because the connections weren’t there yet.  That is changing.

[Tweet “There is an intimate, intricate link between the brain and the gut that scientists are just beginning to understand.”]

Here are some fun facts you should know about what scientists call the gut-brain axis:

  • You have as many neurons (nerve cells) in your gut as you do in your spinal cord.
  • These intestinal nerve cells crank out 90 percent of your body’s serotonin and half of its dopamine. Both of these powerful neurotransmitters help the mind stay calm and focused and are natural anti-depressants.
  • If you go to a doctor for irritable bowel symptoms (such as alternating diarrhea and constipation) or dyspepsia (uncomfortable fullness or pain in the upper abdomen, heartburn, or other digestive problems), you are likely to be prescribed one of the same drugs used to treat anxiety or depression. Doctors don’t really understand why these “brain” drugs work on the gut, but they know that they help make symptoms better.
  • As many as 40 percent of people who go to the doctor with gastrointestinal problems suffer from irritable bowel syndrome and gastroparesis (the stomach muscles or the nerves that drive them stop working, and food doesn’t move out of the stomach the way it should) – conditions that involve the enteric nervous system.  This is the massive highway of nerve cells lining the muscular walls of your esophagus, stomach, intestines, and rectum.
  • These nerves control peristalis, the conveyor-belt series of muscle contractions — think of toothpaste being squeezed through a tube — essential for swallowing, for digestion, absorption of food, and for pooping (literally, movement of the bowels).
  • These enteric nerves also affect immune responses and inflammation.
  • Changes in our mood can also affect everything in the gut.

Is there really a food-mood connection?  Here’s a good example:  An estimated 1 in 133 Americans have celiac disease, an autoimmune disease in which the body attacks the small intestine (this can be diagnosed with a blood test).  The culprit is gluten, which is in wheat.  If you have celiac disease and you don’t change your diet, and you get an upper endoscopy, if you are lucky, it will likely show a telltale “cobblestoning” of the small intestine – damage to the villi, tiny, fingerlike oars that help the small intestine absorb the nutrients in your food.  This damage is reversible.  Within a few weeks of going gluten-free, these little dudes come back and your small intestine can do its job again.  If you are not lucky, a biopsy to the small intestine will show that the celiac disease has caused cancer, and this is not good.

Am I saying you have celiac disease if bread gives you a belly ache? No, but bear with me:  One, a lot of people test negative for the disease itself, but notice they feel bad when they eat bread or pasta.  They feel bloated, maybe a little cranky; maybe they also get headaches.  They also feel better when they eliminate gluten from their diet.  They may have gluten intolerance, which is not the same as celiac disease, but responds well to a change in diet.  Two:  People with celiac disease who give up gluten notice a lot of other changes in their lives.  They may put on muscle mass, because their body was starving from the inside; no matter how much they ate, they weren’t absorbing the good nutrients, because their small intestines didn’t function right.  They also tend to realize, with great surprise, that they have felt bad for years; they just didn’t know why.  And here’s the kicker: Their mood improves.

Celiac disease can cause depression, irritability, and anxiety, but can get better with a diet change.

What I want you to think about is this:  If it can happen with one gut disease, it can happen in other problems involving the gut and/or diet.  Food affects mood.  Maybe you have a food allergy or intolerance that you didn’t know about.  The nerve cells in the gut affect your mood.  It’s the opposite of those ads for Las Vegas:  What happens in the gut does not necessarily stay in the gut.

Food, Body & Mind

“The gut has its own brain,” says Pankaj “Jay” Pasricha, M.D., gastroenterologist and neuroscientist, director of the Center for Digestive Diseases at Johns Hopkins Bayview Medical Center, and co-director of the new Johns Hopkins Food, Body & Mind Center.  At this center, the science is a fusion: it’s Gastroenterology, Neuroscience, Microbiology, Immunology, and Psychiatry.  They’ve got a bunch of doctors and scientists working together to figure out just how important a role the gut plays in diseases that seem like they wouldn’t trouble the intestines – diabetes, heart disease, depression, anxiety, even cancer.

I have interviewed Jay Pasricha several times for the Johns Hopkins Center for Innovative Medicine’s magazine, Breakthrough.  At the Center, he says, many of their patients come to them by way of a rather long road.  Basically, they’ve been through a lot — medicines that may not have worked, for example, or doctors who may have addressed one of their problems without realizing the whole body was involved.  Pasricha told me that his research involves multiple aspects of the gut-brain axis.  He is very interested in the pancreas, in exploring “how the gut can be a signal that drives metabolic disease,” he says, and “finding the mechanism by which gastric bypass surgery relieves insulin resistance and diabetes.” Pasricha has also shown in mouse models of diabetes that there is remodeling of the enteric nerves that help control insulin production; he believes that a new approach to treating diabetes — by changing the way the nerves signal to each other — may be on the horizon.

Enteric nerves

Exactly how the brain in the gut relates to the “big brain” is what Pasricha and his colleagues are working hard to find out, testing the potential of never-before-recognized molecular targets for treatment of nausea, abdominal pain, and other symptoms that may arise when mind-gut pathways go awry.   “The treatment of motility disorders (like irritable bowel disease and gastroparesis) really requires the art as well as the science of medicine, because every patient responds differently,” notes Pasricha.  “In fact, there are very few effective treatments, and what works for one person might not be very helpful for another,” which is why he believes that entirely new avenues of treatment might make a huge difference in care.

But better treatment for motility disorders is most likely just the tip of the gut-brain iceberg, Pasricha believes. The enteric nerves almost certainly play a role in obesity, diabetes, in pancreatitis; they may even be involved in Alzheimer’s disease, some forms of cancer, and other diseases that aren’t usually thought of as relating to the gut.

These nerves are involved in immune responses, he explains, “and this process, called neurogenic inflammation, is a problem in many disabling diseases.” Signals from the enteric nervous system affect metabolism in the brain, liver, and elsewhere.  “The bigger picture here is enormous.”

Next: Bacteria in your gut, good and bad.

©Janet Farrar Worthington

Soothing heartburnEarlier I wrote about the causes of heartburn, also called GERD (gastro-esophageal reflux disease). Now, let’s talk about how to make it better.

First scenario: You’re minding your own business, it’s late at night, you have an attack of heartburn, and you don’t have any medicine. What can you do? Well, you can go to the pantry, and make your own antacid by mixing up 1/2 teaspoon of baking soda in half a glass of water. It will neutralize the acid. But as with any antacid (see below), the effect won’t last forever. Some foods are soothing for the acid-inflamed stomach, as well. Soda crackers (like Saltines) have baking soda, and can help soak up the acid. Also, apples are your friend. Just eating a plain old apple can help disarm the stomach acid. Some people swear by apple cider vinegar:  A tablespoon, mixed with a tablespoon of honey in a cup of warm water can provide temporary relief, as well.

But this is just emergency stuff, best for the occasional flare-up.

The next scenario:  It’s not your first rodeo. You have noticed that you’ve been having heartburn lately, so you’ve bought some Tums. Well, okay. The problem here is that Tums contain calcium carbonate. They will buffer the acid and give you immediate relief. But the calcium actually causes the acid level to bounce back — higher than it was before you took the Tums. This is called rebound hyperacidity. “So an hour later, you are making more acid than you did before, and you’re taking another Tums,” says Prescott, Arizona, gastroenterologist Mark Worthington, M.D. (Disclaimer: I happen to be married to Mark, an excellent, caring physician who was on the faculty at the University of Virginia for 10 years and then on the faculty at Johns Hopkins for five. He’s in private practice now.)

You probably don’t want to live this way, with one surge of stomach acid following another in big, unpleasant waves. Tums are not a good long-term solution for chronic reflux, so let’s move on to drugs.

The next level up from Tums is other antacids:  Rolaids, Maalox, Mylanta, and Gaviscon. These are different from Tums in the chemicals they contain (the names for these compounds end in oxide and ate): Rolaids have calcium carbonate magnesium hydroxide. Maalox and Mylanta contain aluminum hydroxide and magnesium hydroxide, and Gaivscon has aluminum hydroxide and magnesium carbonate. You can get these kinds of antacids as chewable tablets, dissolving tablets, as chewing gum, and in a liquid form. Some of them have a bonus ingredient, like simethicone, which can subdue the gas bubbles percolating in your stomach; Gaviscon’s bonus ingredient is alginic acid, which foams and helps keep what’s in your stomach from creeping back up the esophagus.

“These work for people with heartburn that is occasional and not too severe,” says Worthington, “although the magnesium can cause loose stools (diarrhea).”

However, if you have more frequent bouts of heartburn, you need to move on to the next room in the acid-resisting bunker:  Acid Reducers, also called H2 Receptor Antagonists, or H2 Blockers. These drugs end in “idine.” Pepcid (famotidine), Zantac (ranitidine), Tagamet (cimetidine), Axid (nizatidine). Pepcid Complete combines an acid reducer with an antacid, so it gives immediate relief and then keeps the acid down. Interestingly, although they’re high on the ladder of heartburn remedies, doctors don’t even think of them as particularly high-powered. “These are okay reflux drugs,” says Worthington. “They don’t suppress acid as much as proton pump inhibitors do,” (see below), “which some people see as a benefit.” Why a benefit? Well, if you can get away with taking this level of drugs and having your symptoms controlled, you can still get some of the good out of stomach acid. Long-term lack of stomach acid can lead to bacterial overgrowth (an excess of bacteria) in the small intestine, and a deficiency of magnesium, iron, calcium, and other trace minerals — because it turns out that you need some acid to absorb them.

And that brings us to the big guns:  Proton Pump Inhibitors. These drugs are the “prazoles.” Prevacid (lansoprazole; note: this is different from the less powerful version of Pepcid discussed above), Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Aciphex (rabeprazole). Some of these require a prescription. The good thing is, because they pretty much dry up all the acid in your stomach, they give your poor inflamed esophagus a chance to heal.

And this is really important because your esophagus can only take so much. So if your doctor thinks you need a proton pump inhibitor, you should take it. Because if you don’t treat GERD, it can damage your esophagus. Inflammation in the esophagus, called esophagitis, hurts, and makes it difficult to eat, because you’re in discomfort. Worse, long-term esophagitis can lead to a condition called Barrett’s esophagus — which, in turn, can lead to cancer. This is diagnosed with an upper endoscopy, and the good news is that there is treatment for it, called radiofrequency ablation. “We basically zap the lining of the esophagus with radio waves,” says Worthington. “This causes a very defined, superficial burn, and the Barrett’s tissue sloughs off. It’s like getting a sunburn in the esophagus, but it can save your life.”

There is also a condition called a Schatzki ring. “This is a shelf of scar tissue between the stomach and esophagus,” says Worthington, “and food can get hung up on that when you swallow. It’s called ‘steakhouse syndrome,’ because it’s usually a big piece of steak that gets stuck in there. You feel like you’re having a heart attack, but it’s really just the esophagus having a spasm around the food.” Long-term damage to the esophagus can also lead to development of a stricture — more scar tissue, but instead of a ring, it’s a progressive narrowing, so that food can’t go down very easily. This can be opened up during upper endoscopy, as a gastroenterologist makes tiny cuts in the scar tissue to relax its stranglehold on the esophagus.

Finally, there is surgery, a procedure called fundoplication:  taking the top of the stomach and wrapping it around the esophagus to create an artificial valve — so that what happens in the stomach stays in the stomach. “It works pretty well,” says Worthington, although with this procedure in place, “you can’t burp and you can’t vomit, because if you do, you could rip the stitches.” The fundoplication may not last forever. “They do tend to stretch a little over time, but for people with the most severe reflux, it is not an unreasonable thing to do.”

If you keep having heartburn more than twice a week, what should you do? Well, you can try the lifestyle and diet changes written about in the previous post. If those don’t make your symptoms better, you can start on the remedies here, but the best thing you could do would be to get an upper endoscopy (done by a gastroenterologist, so you’ll need a referral from your primary care doctor), to make sure you don’t have any damage to the esophagus that needs more serious treatment.

 

©Janet Farrar Worthington