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Posted by HFHSM.D.-rf on March 10, 1998 at 22:13:33:
In Reply to: Hyperacidity/intermittent intussusception posted by DS on February 25, 1998 at 20:40:10:
: I am a 34 year old female with no prior history of gastrointestinal problems. Approximately 6 months ago, I suddenly began experiencing chest pain/asthma-like symptoms, burning in my upper back, belching, as well as a dizziness-like feeling after meals (like I was being pushed forward. After heart/lung problems were ruled out, I was put on a 60mg a day dose of Prevacid, which gave me total relief of the chest pain and breathing symptoms, good relief of the dizziness sensation, but not of the burning in my upper back. An EGD was performed after I was on the Prevacid for seven weeks which showed significant recent damage to my esophagus but no Barrett's and no H. Pylori. A 24 hr acid Ph study done while I was on Prevacid (after 9 weeks) was abnormal. About this time I developed a pain in my upper right quadrant and underwent several tests, the only abnormality being a filling defect on my CT scan which appeared to be intussusception in the small bowel. A subsequent small bowel study and enteroclysis were normal. This pain becomes more severe for about 2-3 weeks, then subsides for 2-3 weeks. When the pain is more intense, I have severe malaise. My prevacid dose was then increased to 90 mg which has helped with the dizziness almost completely. I have now been on the 90 mg for over 2 months and have had increasing belching after eating. My gastrin levels have hovered around 100. I began seeing a new gastroenterologist because my old one was at a loss as to what to do. This one seems to think a nissen fundiplication is the answer but says I will have to stay on some dose of proton pump inhibitor the rest of my life anyway. He is not sure what to do about the possible intermittent intussusception. Neither doctor wants me to stay on such a high dose of medication although they both agree I need it. I am concerned about rushing into surgery for something that just seems to have started 6 months ago, especially with this unresolved right upper quadrant pain. Are there other tests I should undergo (besides manometry study) before making this decision?
The symptoms of chest pain, asthma symtoms, and burning could certainly be consistent with reflux esophagitis. The liklihood of this cause is increased by the findings of 1) substantial relief of symptoms with Prevacid, an EGD that showed significant recent esophageal damage but no other abnormalities and an abnormal pH study. The persistence of the burning pain in the upper back may still be due to esophageasl reflux. This opinion is based on the abnormal results from the pH study despite taking Prevacid. Prior to having the surgical procedure I would suggest maximal medical therapy. This therapeutic regimen includes lifestyle modifications and treatment with a prokinetic agent. The lifestyle modifications are directed towards reducing the amount of acid that enters the esophagus. These changes include:
1) eating 3 meals and avoiding snacks
2) avoiding foods that lower the Lower Esophageal Shincter Pressure. Fatty foods, chocolate, pepper,imt should be avoided
3) no cigarettes
4) no alcohol
5) not lying down for several hours after eating
6) sleeping with yiour bed elkvated so that your head is raised approx 6 inches. This goal can be reached by placing books under the legs at the head of the bed
7) chewing gum or sucking candies during the day. The increased saliva that results from these measures will neutralize acid that enters the esophagus.
I am uncertain regarding the cause of your right upper quadrant pain. Intussusception are relatively unusual problems are not often diagnosed by CT scan. Because the intussusception can be intermittent it is not suprising that it was missed by the othere studies. I would suggest that you arrange with your physician to have an UGI series done urgently when you have the pain to confirm whether an intussusception is the cause of your pain. I would also suggest that you be checked for other causes of right upper quadrant pain such as gallstones, pancreatic disease and kidney disease.
This information is provided for educational purposes only and should not be considered a formal evaluation. If you have specific questions regarding your health, you should see your physician.
If you are in the Detroit area and wish to be seen by us call (313) 876-2393 and request an appointment with Dr. zonca one of our experts in the treatment of esophageal disease.
keywords: chest pain, esophageal reflux, proton pump inhibitors, intussusception
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