Proton Pump Inhibitors for Barrett’s Esophagus - An Overview

Creator: Dr. Devanga Manjushree Selvaraj
Published: 2023-01-11T18:11:02

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Proton pump inhibitors are the best therapy provided for Barrett’s esophagus. Read the article below to know more.

Written by

Dr. Devanga Manjushree Selvaraj

Medically reviewed by

Dr. Ghulam Fareed

January 11, 2023

July 17, 2023

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Contents

What Is Barrett’s Esophagus?
What Are the Causes of Barrett’s Esophagus?
What Are the Signs and Symptoms of Barrett’s Esophagus?
What Are the Risk Factors That Are Associated With Barrett’s Esophagus?
How Is the Diagnosis Made for Barrett’s Esophagus?
What Is the Treatment Provided for Barrett’s Esophagus?
What Are the Specifications of Proton Pump Inhibitors for Barrett’s Esophagus?

What Is Barrett's Esophagus?

Barrett's esophagus is a metaplastic condition in which the specialized intestinal metaplasia replaces the squamous cells of the esophageal epithelium. This occurs in about 10 percent of patients who have gastroesophageal reflux diseases (GERD) and also predisposes to dysplasia and adenocarcinoma. Adenocarcinoma is a rapidly increasing cancer than any other cancer. The best treatment provided for this condition is acid suppression by proton pump inhibitors.

What Are the Causes of Barrett's Esophagus?

A long-standing GERD can lead to Barrett's esophagus. The exact cause of the condition is unknown. In some conditions of GERD, individuals do not exhibit any reflux symptoms, known as ‘silent reflux”. The acid reflux may or may not accompany GERD, but this stomach acid and other chemicals present in the stomach wash back into the esophagus, damage the tissue, and trigger endothelial changes in the lining of the causing Barrett's esophagus.

What Are the Signs and Symptoms of Barrett's Esophagus?

In some cases of Barrett's esophagus, the individuals reveal no symptoms. But associated signs and symptoms can be seen, such as acid regurgitation and heartburn. Continuous heartburn that occurs at least twice a week is a major indicator of the condition. Along with heartburn, a burning sensation occurs in the chest with acid regurgitation (vomit sensation in the back of the throat). The other symptoms include:

Worsening sleep along with heartburn.
Vomiting
Blood in stool.
Painful and difficult swallowing.
Feeling of obstructed food in the esophagus.
Constant sore throat.
Sour taste in the mouth.
Bad breath.
Unintentional loss in weight.

What Are the Risk Factors That Are Associated With Barrett's Esophagus?

The risk factors that increase the risk of getting Barrett's esophagus are:

Obesity: Fat accumulation in the abdomen increases the risk of getting Barrett's esophagus.
White Individuals: White individuals are more prone to Barrett's esophagus.
Males: Males get more affected by Barrett's esophagus.
Family History: Any family history of esophageal cancer or Barrett's esophagus can increase the risk of getting Barrett's esophagus.
History of Past or Current Smoking: Any history of smoking can increase risk of getting Barrett's esophagus.
Age: Barrett's esophagus is more common in adults over the age of 50 years, though it can affect people of any age.
Continuous Heartburn and Acid Reflux: Prolong heartburn and acid reflux can increase the chance of having Barrett's esophagus.

How Is the Diagnosis Made for Barrett's Esophagus?

Barrett's esophagus is confirmed by the test called “upper endoscopy”. This test is done by inserting a small tube with a lighted head that passes through the throat into the esophagus, which helps in imaging the change in the lining of the esophagus. The appearance of the esophagus reveals the diagnosis of Barrett's esophagus. Other tests include a tissue biopsy, a tissue sample taken from the esophagus, and observation done under the microscope.

What Is the Treatment Provided for Barrett's Esophagus?

Barrett's esophagus depends largely on the presenting symptoms and dysplasia that is depicted in biopsies. There are many treatments provided for Barrett's esophagus:

Cryotherapy: Liquid nitrogen is used to freeze diseased parts of the esophagus, which sheds the lining of the esophagus. The process is the same as ‘freezing off’ a wart.
Radiofrequency Ablation: Common procedure that burns off tissue using radio waves that generate heat.
Endoscopic Mucosal Resection: An endoscope is used to remove precancerous spots which lie on the esophageal lining.
Surgery: Esophagectomy, a surgery to remove all or part of the esophagus.

What Are the Specifications of Proton Pump Inhibitors for Barrett's Esophagus?

Proton pump inhibitors play the main role in the treatment of patients with Barrett's esophagus:

Control of Reflux Symptoms: Individuals with Barrett's esophagus reveal symptoms like acid regurgitation, heartburn, dysphagia, and chest pain. Proton pump inhibitors provide faster and more huge relief towards heartburn than H2 receptor antagonists. Proton pump inhibitors provide overall symptom relief.

Healing of Coexistent Esophagitis: The healing of existing esophagitis plays a key role in the treatment of Barrett's esophagus. Eliminating the erosive abraded esophagitis so that the erythema of the esophagus permits better delineation of metaplastic epithelium and recognition of dysplasia. Healing of esophagitis is best achieved by proton pump inhibitors, around 84 percent.

Prevention of Recurrence of Esophagitis: Individuals with Barrett's esophagus are more likely to have a recurrence of many physiological abnormalities like lower esophageal sphincter tone and impaired esophageal body peristalsis. Proton pump inhibitors prevent relapses in more than 80 percent of cases.

Healing of Ulcers: Ulcers are responsible for contributing to anemia and gastrointestinal bleeding in 70 percent of cases. Proton pump inhibitors can help these ulcers in around 80 to 90 percent of cases.
Prevention of Stricture Formation: Long-term proton pump inhibitors are necessary to prevent peptic stricture formation; in 70 percent of cases, Barrett's ulcers occur at the squamous-metaplastic junction.
Regression of Metaplastic Surface: Proton pump inhibitors, along with ablative endoscopic modality, is used to lower the risk of the length of the tubular esophagus occupied by intestinal metaplasia. Regression of the metaplastic surface is important in managing individuals with Barrett's esophagus.
Promotion of the Appearance of Squamous Islands: 90 percent of cases of Barrett's esophagus are treated with a proton pump inhibitor to develop squamous islands. These islands reflect the true regression of metaplastic epithelium.
Reduced Duodenal Gastro-esophageal Reflux: The composition of the reflux material is important in Barrett's esophagus. In most cases, the reflux occurs due to acid reflux; though some cases report bile reflux, both reflux tends to go parallel, having a synergistic role. However, aggressive acid suppression therapy along with Omeprazole daily twice increases gastric pH and decreases gastric volume diminishing duodenal gastroesophageal reflux.

Management and Prevention of Dysplasia: Intensive anti reflux therapy along with proton pump inhibitors is given to low-grade dysplasia in order to minimize esophageal inflammation. The maintenance of normal epithelial differentiation and proliferated layer is an important goal of chemoprevention. Proton pump inhibitor therapy has an impact on the regression of dysplasia, but few reports prove the impact of the therapy in an induced reduction in cell proliferation and increased cell differentiation on the development of dysplasia.

Conclusion:

Proton pump inhibitors are the main pharmacological agents that help manage Barrett's esophagus as they prevent strictures, control symptoms, and heal ulcers. Bile induces hyperplasia and metaplasia of the esophageal epithelium, and thus, bile salts are the main contributors to esophageal cancer and Barrett's esophagus. Prolonged use of proton pump inhibitors will increase gastric pH that ionizes the bile salt's transportation during GERD (gastroesophageal reflux disease) and thus help in reducing inflammation. Combining the use of NSAIDs (non-steroidal anti-inflammatory drugs) and proton pump inhibitors is a great therapeutic approach to reducing and maintaining the balance of gastric PH below 4.

Frequently Asked Questions

1. How Frequently Proton Pump Inhibitors Can Be Safely Consumed?

Single dose is the most preferred daily frequency of intake of proton pump inhibitors. However, it can be given at a daily frequency of two times, provided the two doses have a time gap of around 10 to 12 hours. The concerned doctor advises the frequency of the intake of proton pump inhibitors by taking into account the patient's condition, requirement, and severity of the manifestations.

2. What Is the Most Preferred Duration of Therapy Using Proton Pump Inhibitors?

The duration of proton pump therapy varies by the condition for which it is being advised. The severity of the condition and the health status of the patients also influence the treatment duration. In general, the average treatment duration ranges from two to 12 weeks. However, a more extended therapy regimen is also advised for persisting conditions that demand long-term therapy.

3. Why Is It Advised to Consume Proton Pump Inhibitors When the Stomach Is Empty?

The utmost potency and efficacy of proton pump inhibitor therapy are attained when the medicine is taken on an empty stomach. During food intake, the proton pumps that enhance the digestive juice discharge are triggered to their active state. As a result, proton pump inhibitor action will be compromised. When introduced prior, proton pump inhibitors are more successful in eliciting its inhibitory effects on the proton pumps.

4. What Are the Consequences of Taking Proton Pump Inhibitors More Than the Recommended Dosage?

Taking more than the prescribed dosage of proton pump inhibitors can potentially give rise to overdose issues. In the event of an overdose, the body’s electrolyte balance will be considerably impaired as the drug molecules impede the proton pumps. There will be enhanced adverse effects on the body in the form of gastrointestinal issues like vomiting and stomach pain. Persistent intake of proton pump inhibitors also compromises bone health.

5. What Is the Most Advisable Time for the Intake of Proton Pump Inhibitors?

Morning intake before breakfast is the ideal time to intake proton pump inhibitors. This ensures sufficient time for the PPI to exert its effects on the proton pumps without being interrupted by the presence of food. If advised twice daily, the ideal time for PPI administration is morning (before breakfast) and night (before dinner). There should be a minimum of a 30 to 60-minute time gap between drug intake and food intake.

6. Are Proton Pump Inhibitors Safe When Taken Alongside Other Medicines?

Though proton pumps are often advised alongside antibiotics and other drugs, there are certain medicines with which PPI elicits unwanted interactions. Concurrent administration of PPI with antiplatelet medicines like Clopitrogrel or Aspirin mitigates the effectiveness of the antiplatelet medicines. It also elicits adverse interactions with certain anticancer medicines.

7. Are Proton Pump Inhibitors Effective When Consumed on an Alternate Day Basis?

Proton pump inhibitors are routinely advised daily. However, there are instances when a minimal dose of PPI medicine is needed for administration every second day instead of every day. The concerned healthcare practitioner determines the dosage frequency and course by considering the patient's medical needs. Acid reflux in the absence of Barrett’s esophagus is one such medical condition affecting the stomach where alternate-day therapy using PPI is effective.

8. What Is the Estimated Effectiveness Rate for Proton Pump Inhibitors?

Proton pump inhibitors demonstrated effectiveness in the 75 to 80 percent range. The therapeutic benefit of PPI on par with other placebo (dummy pills) medicines was estimated through various clinical studies. It was found to be 30 to 35 percent for tackling heartburn (sense of flaming chest). Enhanced resolution of the ulcerative lesion in the stomach is reported with PPI rather than the conventional H2 blocker medicines.

9. How Does the Digestive Process Take Place While Undergoing Proton Pump Inhibitor Therapy?

Most patients have concerns regarding food digestion while undergoing therapy using proton pump inhibitors. However, PPI does not completely check the digestion process. Though PPI curbs the acidity of the digestive juice, there will be enough digestive enzymes to act on the food particles. The functions of the peptic enzyme will be diminished by the actions of PPI, which decelerate the breaking down of food particles. It delays the movement of food through the stomach.

10. What Are the Disease Conditions for Which Proton Pump Inhibitor Therapy Is Advised on a Long-Term Basis?

Reflux disease is an obvious indication, which entails long-term therapy using proton pump inhibitors. In acid reflux disease, the patients regurgitate and bring the stomach content back into the mouth. Another indication is for patients who are undergoing long-term treatment therapy using non-steroidal anti-inflammatory drugs (NSAIDs) to check for the development of NSAID-triggered gastric issues.

11. What Is the Rationale Behind Administering Proton Pump Inhibitors Along With Antibiotics?

Certain proton pump inhibitors are often advised along with antibiotic therapy. The rationale behind this simultaneous administration is to eliminate and mitigate the risk of Helicobacter pylori infection. PPI enables the antibiotics to elicit their actions in the stomach by impeding gastric secretion and making the gastric environment favorable for the antibiotic to act upon.

However, not all antibiotics are suitable to be given along with PPI, and the doctor determines the choice of medicine.

12. Who Is Not Supposed to Take Proton Pump Inhibitors?

Patients who have had prior allergic encounters with PPI or any component present in the prescribed PPI should refrain from PPI therapy. Compromised immunity and hepatic functions also contraindicate therapy using PPI. Patients with liver impairments, particularly those mitigating the activities of cytochrome enzymes, are also contraindicated for undergoing PPI therapy. Therefore, it is imperative to discuss with the doctor the choice of medicine before initiating any pharmacological therapy.

13. In Which Part of the Body Do Proton Pumps Are Present?

The cells that line the inner stomach express gastric proton pumps on their surfaces. These proton pumps contribute to gastric pH and acid secretion. These pumps drive hydrogen ions into the digestive juice, enhancing the stomach content's acidity. Proton pump inhibitor medicines work on these proton pumps and gear down the gastric acidity.

14. Do Proton Pump Inhibitors Interrupt the Electrolyte Balance in the Body?

Proton pump inhibitors are known to precipitate electrolyte imbalances in the body. Hypomagnesemia, hypophosphatemia, hypokalemia, hyponatremia, and hypocalcemia are various electrolyte imbalance conditions that develop as a consequence of prolonged therapy using PPI. At times, multiple electrolyte imbalances develop simultaneously in response to long-term PPI therapy.

Sources

Dr. Ghulam Fareed

Medical Gastroenterology

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