Dear Dr. Roach: I am a 75-year-old woman in very good health with the exception of my Barrett’s esophagus, which I have had for five years with no dysplasia. My gastroenterologist had prescribed 20 mg of omeprazole once a day for those five years. He thought that a dose this small is not a problem. I seem to have had no ill effects, according to the yearly blood work from my primary care physician, but I am concerned about the long-term usage of this drug. Could you please advise?
P.C.
The esophagus carries food from the mouth to the stomach. There is a valve-like structure called the lower esophageal sphincter at the bottom of the esophagus, which is supposed to keep food and acid in the stomach. Gastroesophageal reflux is a failure of the lower esophageal sphincter, causing heartburn and other symptoms.
Barrett’s esophagus is a condition where, after years of acid reflux, the lining of the esophagus becomes more like the lining of the stomach. This condition, metaplasia, is not cancerous in itself, but it predisposes patients to the development of a specific cancer of the esophagus called adenocarcinoma.
Omeprazole works by inhibiting the proton pump, which is responsible for strong acid in the stomach. It is believed, but not proven, that reducing acid in the stomach will reduce the risk of developing adenocarcinoma of the esophagus, and observational studies have suggested a drop of about 50% in cancer risk. Most experts believe the smaller, 20-mg dose is as effective as a higher dose, and higher doses are more likely to cause adverse effects.
Even at lower doses, there is still the possibility of harm from long-term use of proton pump inhibitors like omeprazole. Infections, especially Clostridioides difficile, are more likely. It’s harder to absorb vitamin B12 and calcium carbonate, so sometimes supplementation is needed. There may be other conditions with a small long-term risk.
However, since adenocarcinoma of the esophagus is a terrible disease with high mortality risk, the consensus is that there is far more benefit than harm in treating people with Barrett’s esophagus with a proton pump inhibitor. In addition, regular surveillance of the esophagus is recommended. Studies are ongoing to see whether periodic endoscopies will reduce the risk of developing or dying from esophageal cancer, but until there is firm data, I recommend both surveillance and continuing omeprazole.
Dear Dr. Roach: In a recent column, you discussed medications and supplements for constipation. I tried most of those, including Linzess. I suffered with constipation for 30 years, but nothing worked consistently until I found a gastroenterologist who referred me to a pelvic floor physical therapist. The therapist hoped that she could improve my motility by at least 25%, but I achieved 100% motility within three months! By continuing with home exercises, abdominal crunches and diaphragmatic breathing, I have had daily bowel movements for the past eight months. I hope that you will recommend this to your readers; it has changed my life.
B.A.
I appreciate your writing, as this was something I did not know about until you wrote. I found studies showing 50% to 75% of people with constipation can see improvement with pelvic floor physical therapy, a type of therapy that requires special training and, unfortunately, is not always easy to find. Any non-medication alternatives are welcome.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
