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Bravo 48hr Ph DeMeester score yields confusing (to me) results
A while back (almost a year ago) I had a Bravo 48hr Ph test done. Today I went to my gastroenterologist and while we discussed the results before, we delved deeper into their meaning today. After getting some numbers, I became more confused (after some post-visit research) because according to the test I'm not really supposed to have heartburn (opening the possibility of other esophageal issues). Here are the numbers:

- DeMeester score: 8.9 (<14.23 = normal)
- Total # of events: 89 (<50 every 24hrs = normal)
- Events over 5 minutes: 0
- Total exposure time: 2.6% (~4.5% = normal)
- All events occurred when standing/sitting. None when laying down.

By all metrics, I'm pretty normal, except I get symptoms all the time. (More lately that I've gained some weight.) However, I still get enough heartburn to get esophagitis symptoms (once in a while, particularly when ill), so I tend to take PPIs.

My question: Am I simply overtly sensitive?

Background:
- diagnosed with mild gastroparesis in 2007 (for which I take Domperidone)
- prone to anxiety episodes
- current weight: 244lbs as of testing (prior: 236)
- gallbladder removed 05/2009
- sliding hiatal hernia which was there 12 yrs ago, then not there 3 years ago, may be back now (EGD scheduled for next month).

Grateful for any and all input.
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620923 tn?1452919248
Hi...long time no see !!...sorry u r still dealing with the same issues tho.....

Have u or the dr considered that ur acid levels r too low?....I know u can feel like they r high....it feels the same...and with getting the PH test done and knowing that they r "normal" mayb "normal" is too low for u and the meds make it worse....mayb a probiotic to balance things out?

U had ur GB out a while ago too, since then were u tested for H.Pylori?.....

I am sure we covered this same ground b4, I can't remember...but it is a thought for now in case I didn't.

Praying u get answers soon

"selma"
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Hey Selma! I really do wish our next meeting was running into each other at Disney World or the mall or anywhere else but under these circumstances. *grr*

As for too little acid, it's unlikely. Last endoscopy I had revealed esophageal erosion w/mild esophagitis, so there was definitelly too much acid there. Meds make it better when they work. Recently I had gone off the pills again and gotten slick with a heavy cold/light flu, and the acid kicked up fearce. It doesn't help that I'd fallen back on patterns of over eating and eating the wrong foods, causing me to regain 10lbs. (mM dad runs a pizza shop now, so you can imagine.) If the price of freedom is eternal vigilance, then I lost my freedom, at least from acid. Mia culpa.

As for H. Pylori, that's an interesting question. I don't think I've exposed myself to an infection, but it's certainly a possibility to watch. After the GB removal things were spectacular for a while, but no tests have been done. The next scheduled test is an EGD, so if anything is revealed, it'll be then.

I've been reading studies that show that acid can cause esophageal sensitivity, so maybe that's it. My big fear is that I'm developing (or have developed) Barrett's, something which utterly frightens me. Indeed, symptoms don't really bother me at all (in that I don't mind them, generally): it is the thought of this and all that comes with it which frightens me most.

As of late, a few very definite symptoms are showing up, like my gastroparesis totally flaring after my cold/flu (my worst flares seem to coincidee with flus) and my getting pretty regular (I dare say constant, hours after meals) regurgitation. I'm starting to wonder whether I might have another esophageal issue, perhaps something involving motility (which coincides with this latest gastroparesic flare) and what the role of a hiatal hernia may be in all this.

Thank you for your advice & listening.
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620923 tn?1452919248
I would love to meet that way too...but alas it is not to be....lol....sigh


Well u can  have a flare with ne change in weight be it up or down...and Pizza !!...well u know the drill....

Do u take PPI's ....cause I took them for yrs and they just stopped working one day.....I was switched to the H2 inhibitors and they work soooooo much better....u can take them b4 u eat the Pizza and the acid does not form......once u get a balance back I am sure u will be ok.....if u had barretts wouldn't u dr have been able to detect it already?

I also have had many get flare ups while having the flu......well u know the hernia will be an active participant in all this, but the dr in the expert forum is talking about seeing chiropractors that know how to manipulate the hernia into a lower position to get relief with out need for the Nissen.....check out the live chat-
http://www.medhelp.org/posts/GERD-Acid-Reflux/GERD-HEARTBURN--HEALTH-CHAT--REGISTER-NOW/show/1181506

Nice talking to u again...so sorry under these conditions

"selma"
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Alright, joined the conference and added a question. (Basically, what are the side effects of TIF in comparison to traditional fundoplication? My doc has not discussed TIF, but has been hesitant to suggest a surgical solution because of my gastroparesis and fear of gas/bloat syndrome). I've also talked to chiropractors about that subject, and they've all said the same thing: they can't do anything about that, although I do have a numb spot in the back, and they've said that maybe that has something to do with it. Previous treatment yielded some results, but it seems as if full resolution is unlikely.

I do take PPI's, but under this doctor's recommendation I began taking them on an on/off basis. Unfortunately, now he tells me that while he's never seen anyone on PPI therapy develop Barret's, he can't make a prediction in my case. *grr* I've been taking PPIs again steadily for a week, but my esophagus still hurts while swallowing, particularly foods that are "sticky", like chewed bananas. (Liquids tend not to affect it, and I haven't been able to eat solid foods for a few days, so I can't say anything as to the status of that.) Esophageal dysmotility has been mentioned before as a possibility, but lacking the equipment, my doc's not been able to run these tests (or given me the information on how I can get this knowledge somewhere else.) My stomach is definitely showing signs of gastritis. PPI's have been helping there.

I've taken H2-inhibitors in the past and they haven't been much help. Until after my endoscopy, I can't say.

I've been trying to find a good acupuncturist in this area but costs are high with these folks, esp. since my insurance doesn't cover them. (*sigh* What I wouldn't give to not have to worry about pithy little things, like money...)
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620923 tn?1452919248
....same here on the money issue....lol...

I can not say much on the TIF as I am not familiar and I know many r talking about it...did u ask about it on the chat?
******************************************************************************************************
I am posting info on TIF for those that may read this an do not know what it may be.....

About the TIF Procedure
The Transoral Incisionless Fundoplication (TIF) procedure is an incisionless transoral NOS (Natural Orifice Surgery) surgical procedure for the treatment of reflux disease. Made possible through the use of the innovative EsophyX surgical device, the device is introduced into the body through the mouth, not through an incision. The advantages of incisionless surgery over laparoscopic or open surgery include shorter hospital stay, reduced patient discomfort, shortened patient recovery, no scars, and typically higher patient satisfaction.

The clinically-proven TIF procedure is based on years of proven surgical concepts and techniques. TIF works by reconstructing a robust antireflux barrier at the gastroesophageal junction, restoring natural anatomical geometry to effectively treat GERD.

******************************************************************************************************

I understand u were rx'd the PPI's I was too and they stopped working and it does happen....and the rx strength of H2's r working better for me that the PPI's did...I am interested in finding more on the chiropractors manipulation of the hiatal hernia to give relief with out surgery...I understand that just ne chiro will not be able to help...sounds like a new technique that only a few know how to do....if mine ever gets really bad, I would try this first b4 surgery...I have had enuff 4 now and have 2 others hanging over my head...so I deff want to put the thought of yet another one off.

.....and I do know I do have to watch my diet...and I can eat pizza and things like that , but in moderation...like we all should do neway...lol....and I am not a big soda drinker either...not too many vices.....except my chocolate...dark chocolate : )


I pray u feel better soon.

"selma"

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I just had my monitor put in last night.  I think it is not the best test for me because I do have stage 3 barretts and I am like you the PPI's work when they work.  But the doctor said I have to have this test so the insurance will pay for the surgery.  What more does the insurance want my first born...LOL but although I have enought acid that I have Barretts stage 3, I am worried im going to fail this test.  They took me off my PPI's last wed. and since then I too have gotten a bad cold/flu.  I hope you find answers soon, I feel like we are all walking in the dark with this monitor that is deciding our future health...    
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If anything the bad cold/flu should help your case: Your stomach starts creating all kinds of acid when you're sick as part of its defense mechanism. (Acid destroys a fair number of bacteria.)
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By the way, to anyone reading this, it was discovered just recently that the issue now might not be acid reflux at all, but rather Eosinophilic Esophagitis, which causes many of the same symptoms. A recent EGD revealed that I had ~15 eosinophils per HPF in multiple biopsies, which is enough for a diagnosis of EoE.

I'm getting together with my allergist next week and my gastroenterologist the week after that to discuss options. For the moment, though, I'm on the "pretty much nothing but rice and veggies" diet. (The challenge is finding a suitable protein source to which I'm NOT allergic. Nuts seem to fit the bill, but I'm still testing these.)
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620923 tn?1452919248
Hi...what?...allergies?

Goodness how did they miss this?

Please keep us posted on what u find out at that next visit.....and good luck with the diet...I pray u find more that u can eat.

"selma"
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These might be new allergies. I know I had an allergy problem before, and I definitely did have erosive esophagitis at one point, but my recent issues may have indeed been caught by allergies for which they didn't previously test.

With that said, I'm still on my Nexium for the time being, and foresee being on it until I lose the weight I need to lose. (My reflux gets a lot better when I lose weight. As of this morning I've lost 94 lbs.) I can't help but wonder whether, considering the GERD, the eosinophil count was driven up by acid, rather than by allergens alone, even though my recent diet, as it turns out, was comprised of one allergic food followed by another and another. In fact, it may be that my acid reflux has been almost entirely caused by lactose (oops, didn't realize I was intolerant!), allergies, and weight, with the second contributing far more than I'd previously imagined.

I'll keep you updated, selmaS, and if there's anything relevant to this thread, I'll be sure to add it.
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620923 tn?1452919248
CONGRATULATIONS on the weight loss!! WOW...I am sure u will see improved health as a result, but I am sure u know, reflux will flare even as u lose weight as well as gain or if u r overweight...so , until u get to a maintained level u may have small flares.

But I am so impressed : D

I look forward to ur updates : )

"selma"
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Hi,
Ok didn't read everything but from what I know (studying medicine for the moment), the pH monitoring is supposed to show the severity of the acid reflux but according to studies there is little or no correlation between the amount of acid refluxed and the severity of symptoms. They are simply subjective to each and every one.
So the low Demeester score is nothing but good for you :)
However you mentioned in the beginning that the episodes occured when sitting/standing. Did you live as normal during the test or did you avoid lying down (possible bias).

As for the Barretts, it's a complication of severe & long standing reflux, and when making EGD, one of the purposes is to biopsy (or use othe staining methods of the mucosa), to check for Barrett's changes. So your doctor is definitely aware of this, but talk to him if you feel insecure.

As for the medication with PPI:s it's important to be compliant. A round of PPIs should be taken for about 8 weeks (20-40 mg/day) in GERD. If you abort treatment after 2 weeks or when it feels better it's useless.
Another problem that can occur is rebound acidity after stopping the PPIs. Which means that the suppression of the acid during long time will rebound causing hyperacidity if stopped abruptly. So a tapering down of the dose towards the end is recommended.
Another option after the PPI treatment is over is to take a long-term maintainance treatment with H2 blockers to prevent recurrences of GERD.

The last and maybe most important part is that you MUST!!!!! change your lifestyle. Without this no meds will help. They're not magical pills but only help you.
--> WEIGHT LOSS, exercise, STOP intake of large meals (especially with the gastroparesis), NO smoking, NO drinking alcohol, be careful with citrus juices or tomato based products & strong spices (also irritates the esophageal mucosa)!!!!!!

Also if you're on heart/BP-medications such as Calcium channel blockers or Nitrates these might exacerbate the reflux.


Ok I think that's about it :). I really wish you good luck but remember that the only thing your doctor can do is to give you advice and to investigate you. The real success of the treatment is in your hands mostly. Compliance and lifestyle is very important and if you really follw this and nothing helps then other options such as fundoplication could be taken into consideration.

All the best wishes
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