Tuesday, November 24, 2009

Corrosive Stomach Acid

By Shawn Vuong

A wise pharmacology professor once told me, "All substances are poisons; there is none which is not a poison.  The right dose differentiates a poison and a remedy."  

This week Dr. Holm talks about drugs, particularly in the context of heart burn.  In our pharmacology class, we are learning about how all types of drugs interact with the body.  Prescription drugs, over-the-counter drugs, herbals, and even supplements all effect the body in different ways.  The key to prescribing drugs correctly is weighing the risk of toxicity of a drug versus the benefit gained. 

Each substance has it's own toxic effect when given at too high of doses.  But we must make the dose high enough to see a benefit.  In effect, we get a titer-totter like scenario where we are trying to balance the correct dose to see benefit while trying to limit toxic effects (also known as side effects).  Some drugs are easy to give, since they have a high benefit but low toxic effects such as statins.  Other drugs have medical health professions constantly walking that fine line between lethal effects and benefit to the patient such as chemotherapy agents or anesthetics.  

So remember, every substance has toxic effects when given at incorrect doses.  Even water can cause lethal effects if you drink too much.  So, please work with your doctor to correctly dose your medications, because they can sometimes give you nasty side-effects.  


By Richard P. Holm MD

It has always amazed me that the stomach can produce large amounts of a very corrosive hydrochloric acid. Of course, we do that in order to breakdown food so our bodies can absorb nutrients.

In response to food stretching the stomach and esophagus, tiny proton-pumps in special cells that line the stomach make acidic stomach juice. The resultant strength of gastric acid during digestions can be not as corrosive as battery acid, but almost.

Fortunately, a special layer of mucus protects the stomach from the acid, and as food moves on into the small intestine, the corrosive juice is neutralized by sodium bicarbonate produced by the pancreas.

When something goes wrong: the stomach-mucus layer fails; the acid rolls up into the unprotected esophagus; or there is not enough sodium bicarbonate to neutralize the acid… then symptoms occur. People can be pretty miserable as digestive juices are eating away at their own tissue, rather than the food they just ate.

Fortunately we have very effective medications to reduce acid production when something goes awry. One group of antacids, which reduce acid quickly are the H2 blockers with ranitidine (Zantac) as an example. Another group, which reduce acid slower but more effectively, are the proton-pump inhibitors, with omeprazole (Prilosec) as an example.

These two types of powerful antacids have been a blessing for many people who truly suffer from excess acid stomach. A major drawback with both types of medicines, however, comes when trying to stop them, which can result in rebound acidity.

A recent study provided two months of omeprazole to people who at start had never been troubled with heartburn. When the medicine was stopped, however, the volunteers had rebound acid symptoms.

People need to be warned when using these stomach acid medicines that short-term use is safe and can be very helpful. However, getting off of them after prolonged use can be a challenge and may require a gradual reduction over two to three months. Certainly some people should never be off of them, but that should be discussed with your doctor.

Take home message: we have good medicines to counter the corrosive battery-like acid made in our stomachs, but they need to be used with caution.

Sunday, November 1, 2009


By Shawn Vuong

This post from Dr. Holm really hits home with me.  In my late elementary school/early middle school years I was plagued with exercise-induced asthma.  When I would play in PE class or recess, my chest would just feel like it was tightening up.  The wheezing, the tightness, and the shortness of breath is very scary. 

My parents took me to a pediatric pulmonologist and I was tested for asthma.  Right then, the doctor prescribed me an albuterol inhaler, which became my life line.  After that, any physical activity that I did was preceded by a couple puffs from my inhaler.  I was too scared to have another asthma episode.  

Asthma is not just something that is brought on by exercise, but can be induced by allergies, pollutants, smoking, chronic disease, infections, or even stress.  Asthma can be deadly.  If you think you have some of the signs or symptoms of asthma I encourage you to see your doctor.  


By Richard P. Holm MD

A few years ago, a 40-something woman was walking across the farm yard when something in the air brought on wheezing, like gangbusters. She turned back to the house for her inhaler, but just couldn't make it, and collapsed in the yard.

While her husband was hurriedly driving her to town, she stopped breathing entirely. Her husband gave her mouth-to-mouth until the ambulance met them.

In the ER, we were able to place the breathing tube down, but her brain had been too long without oxygen. And a few days later, I will never forget how she gently escaped from this earth surrounded by her loving family.

This tragic death taught me how asthma kills. So what can we do to prevent a similar calamity?

First, recognize when you are at risk. Have you experienced an asthma attack that comes on fast and out of the blue?

Next: are you using your rescue-immediate-acting inhaler more often lately? I should add here that albuterol or any of the fast acting adrenaline-like asthma inhalers might cover-up or even cause worsening inflammation in the lungs. They only work for the short run-and increased use of these fast acting rescue meds is a big time danger signal.

Finally: know that when your asthma is accelerating you need to turn off the inflammation and our best tool to do that is a steroid. Not a body building type, but and anti-inflammatory which slowly turns off asthma for the long run.

That's the take home message: although fast acting rescue inhalers are good to have-they forecast danger. The real hero in this disease is the anti-inflammatory steroid inhalers.

So if you or your family member with asthma is using the rescue inhalers more than usual do not dally. You need to be talking to your doctor about anti-inflammatory steroids.

Earwax and Elbows

By Shawn Vuong

In this post, Dr. Holm talks about one topic that doctors have been losing ground on for a long time, the Q Tip.  Every physician from the ENT to the family practitioner has seen the damage Q Tips have caused eardrums and ear canals.  They warn their patients to not stick anything into their ears, and to let ear wax come out naturally. I remember when I was in grade school, some health professional came in and told us only to use a wash cloth to clean out our ears and to never use a Q Tip.  Almost 20 years later, I still use them like a bad habit.  

Using Q Tips and Bobby Pins to clean out your ears is a bad habit, although it may seem like you are doing it to keep your ears clean.  In this case, the gross wax that a person is trying to clean out of the ear canal is actually the stuff you want in there for protection.  Dr. Holm explains more about the Q Tip problem, and gives some better solutions to cleaning out one's ears.  


By Richard P. Holm MD

It was 1973, and the Professor advised our Sophomore Med School class that the smallest thing that should ever go into the ear canal is your elbow.  Through 31 years of practice I have seen many injuries to ears resulting mostly from Q Tips and Bobby Pins.  People use these weapons sometimes to scratch an ear itch, but mostly to remove earwax. 

Earwax is an oft-maligned material that has an interesting story.

Recently scientists have discovered genetic differences by the character of earwax.  East Asians and American Indians are more likely to have a dry grey and flaky type of wax, while Africans and Caucasians are more likely to have the moist honey-brown type.  Anthropologists have even used earwax type to track human migratory patterns, and claim the dry type indicates a genetic change, which came as a beneficial reduction in sweating for those living in cold climates.

Also called cerumen, the stuff that comes out of ears is a mixture of oil, sweat, and old sloughed off ear canal skin. As we chew, the jaw movement moves the gooey stuff outward down the canal, dragging with it dirt, dust, and debris.  We know it also provides for lubrication and protection against bacteria and fungus.

With aging, dehydration, or metabolic problems, the earwax can sometimes thicken, stop moving, fill the ear canals, and cause trouble.  In this case one should apply a couple drops of warm olive oil or baby oil to each ear two or three times a week. 

Q-Tips or Bobby Pins should be avoided since they will only pack the wax and potentially perforate the eardrum.  If oil fails to drain the wax plug, a few weeks of drops will at least prepare the wax for removal.  Then a solution of warm (not hot or cold) vinegar-water irrigated by an inexpensive ear syringe purchased at any drugstore should clear the plug.  Failing that, see your doctor.

There’s lots to do besides putting your elbow up there.