Reflux Help

[davepr]

Hi, I am a 41 year old white male. I have had reflux problem for the last 10 years or so. I also have a mild hietal hernia.
I have been on Nexium and Prilosec for the last few years.

Recently I started to experience alot of chest pain. I went to my doctor, she did some blood work and EKG, ruled out any heart problems. We both thought it was GI problem but I did not have
the typical "heart burn"

My symptons are mainly chest pain, worse after a meal or any
alchol, and bad a night. It can also ben bad on an empty stomach. I have alot of burping going on but not any real heart burn, ie burning sensation, just the pain, bumping, and some
slight difficult swollowing.

I went to my GI specialist, he did some blood tests, they came back negative. He also did the 24 hour PH study, still waiting on my results of this but I did see that the PH monitor dropped
below 4.0 many times, about 10-20 times per day and as low as 1.0. It was difficult to corulate this to the pain as the
pain is there pretty much all the time, it just gets worse after a meal, on a empty stomach or laying down.

I also had an endoscope done, he said the results were normal there and the hietal hernia was still small. I also had the tests where the place the tube down your throat and take pressure readings at various spots, that was normal.

My GI specialist told me that since the high does of Nexium and Prilosec have not worked, he is leaning toward surgery. HE stared me on Zegrid 40mg twice a day as a last resort, just started that this morning.

Does surgery sound like the best option for this? Is it normal to have acid reflux without any real burning sensation and just chest pain and burping/gas? Any advise would be greatly appreciated. Thanks

[Kevin Pho, MD]

Yes, it is possible to have reflux without any overt symptoms - although this is atypical.

If medical options such as Nexium and Prilosec are not working, then one would lean towards surgical or endoscopic options.  

The surgical options include a fundoplication - which can solve the issue of refractory heartburn.  

There are also some investigational endoscopic options - such as sewing or plication techniques.  These are investigational, and are mainly tried in those with uncomplicated GERD.

These options can be discussed with your gastroenterologist.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
http://www.straightfromthedoc.com

[TJV]

   If your ph readings only  dropped below 4  -- 10 or 20  times a day , that would be considered  perfectly normal .  Everyone refluxes. Normal people without GERD  can reflux up to 50 times a day.

The ph meter also has to be below 4.... for 5 or 6 percent of the time ( depending on the examiner's scoring) They also take into account longest reflux episode, how many reflux episodes were longer than 5 minutes , upright and supine reflux, and correlation to symptoms of course ....

Hiatal hernias don't normally get larger.  A gastric emptying study may be useful , and an acid perfusion test ( Bernstein test)  to see if chest pain is acid caused  ...... that is if your ph results are inconclusive.

Regardless , people who don't respond to PPIS generally don't respond to surgery as well , and there are plenty of undesirable side effects attached to this surgery.    Also many people end up back on PPIS.   Surgery should be a VERY  last resort.  Your doctor could add a pro motility drug to see if that helps . Also you could try zantac at night  . That may help more.

  

[davepr]

Thanks for the reply, I did try Zantec at night some time ago without much improvement.

[TJV]

  I assume you had an ultrasound , gallbladder checked etc.   You could also have a ph test while on your meds to see if in fact the PPIS are working. In many people who think they are not working, the PH test comes out normal.  

  Here's a GERD site you may want to look at.  http://forums.heartburn-help.com/ There is a Nissen fundoplication forum where lots of people have had the op and talk about their experiences.  There is a section with questions to ask the surgeon as well.

  If you do decide to have the op, the surgeon is everything . Make sure you choose the right one and he has PLENTY of experience with this type of surgery.

  Many people with NERD ( non erosive reflux disease )   have symptoms that come and go and they are able to eventually step down on their medications,   or take on demand therapy.
  

[Kpetrush]

I was just reading over refux help posted by dtp.  I am 19 and have suffered with reflux since i've been born.  About 3 years ago, My refluz became so bad i started to lose weight and get very sick from it.  It wasn't typical reflux (although thats what it was diagnosed as) because if i would simply bend over after a meal it would fall out of my stomach through my mouth.  After years of testing, people telling me i had an eating disorder, a doctor in the area reccommend that i have a nissen fundoplication performed WITHOUT a monometry study (HUGE MISTAKE).  Turns out that I contracted Nutcracker Esophagus and that is where my chest pain comes in.  i had the surgery and it turns out that was the last thing that i should have had becuase of my chest pain.  the fundopication was reversed at the mayo clinic and i have been being treated for nutcracker with a slew of medicines (more than i can count, i am still on the acid mediicne protonix) but i have been a guinea pig to try and find somethingg that can help manage my chest pain.  I used to have botox injected into my esophagus and that would make the pain go away for about six months.  I am currently in terrible shape, i am about 5'5"-5'6" and weigh 107 lbs.  I am always in pain, but yet, don't reflux anymore.  it's as though my nutcracker esophagus has taken control of my life.  I notice my pain is brough on by meals that have tough or full texture (hamburgers, steak, sandwhiches, etc.) Anything that is pretty much not soupy consistency will cause my pain.  But, it's not always food that brings on my pain.  Latley when i've been trying to fall asleep the pain is horrible and when i wake up.  I also notice that if i dont get enough sleep my chest will kill me.  Any type of physical activty seems to bother me as well, i am not sure why.  Make sure if you are going t have surgery you have a monometry performed before, if not once, a coupl times.  It's hard to time it just right to have chest pain on the exact moment and day of your test.  I am desperate to try and find something to make me feel better.  Becase of the chest pain i can hardly eat, i have a hard time with just doing everyday things in life and the doctors say they don't have any reason why this "nutcracker" esophagus has effected me.  they say it is commonly brought on by reflux, butnot all reflux sufferes get this problem.  i have tried every type of medicine that is avaliable and the only thing that even slightly helps is pain medicine.  I am afraid because i dont want my doctors to think that i am simply after the medicine, i want something to help me.  I am only 19 years old and would give anything to have the last 3 years of my life back that were spent traveling all over the country to try and get me to feeling better.  I am headed up to yet another specialist in the state in about a month and odn't know how i am going to get by until then.  I pray every day that some miracle happens and i am fixed.  i wanted to post this story so that you really research your doctor and you get ALL tests performed that they can possibly do so that you don't have to go through what i did with misdiagnosis and other problems surrounding this problem.  There is much, much more to this whole ordeal, it's just hard to explain it all.  so, i wish you luck with figuring out what youve got and i hope that finding something that makes you feel better can be a WHOLE lot easier than it has been for me.  Maybe someday soon i can feel better, although my Mayo clinic doctor i will never be normal again. good luck with all.

[TJV]

  Hi  Did you have a total takedown of your fundoplication, or a takedown to a partial fundoplication?  They normally reccomend only  partial fundoplication for nutcraker.

They don't usually  totally take down a fundo  without replacing it with something,  because GERD will be a problem again. ,  When they do a fundo op initially , they sort of destroy the normal anti reflux mechinism , and then build a wrap to replace it. If the fundo is all taken down with nothing to replace it , there will be problems with GERD and thus aggravate the nutcracker esophagus.

    Regarding GERD ,   that does not cause Nutcracker esophagus. It highly agravates it. Increased release of  acetylcholine appears to be a factor, but the triggering event is not known.    

In those with both GERD and nutcracker esophagus   GERD most often is beleived  the cause of symptoms ( that's why they have you on PPIS)  , and not the motility disorder  at all,   as the clinical relevance of nutcracker esophagus is questionable......  and  may involve   a dysfunction of the visceral pain sensory mechanisms. The clinical revelence of Nutcracker is questionable because many normal  people have the motility patterns of  nutcracker esophagus on manometry , but absolutely no symptoms.

Meds for viceral pain may work the best, along with the PPIS.

  

[davepr]

Just got the results from my 24 hour PH test, the doctor said it was consistant with reflux and they scheduled me to see a surgeon, I see him later this week. Thanks

[Kpetrush]

So then what types of medicines are prescribed for visceral pain?  I had a compelte take down surgery, and my gerd is somewhat of a problem but not too bad anymore.  i domnt know why that is.  I suppose becuase before it was not typical reflux but im not sure.  now much question is what type of medicines genrally work for visceral pain, and exactly what is it? thanks.

[nessie1]

kpetrush:  Not necessarily a long shot here but certainly worth mentioning.  My mother was diagnosed as were you - long, long ago.  After multitudes of years of medications it was later discovered that she never had reflux all along but rather (excuse my terminology) a 'crimped' celiac artery.  Definately worth asking your doctors about since she had this as well since she was a child.  She always complained of having an elephant in her chest until it was discovered and repaired.

[Pattie P]

My Husband went for a Upper GI today and was told he has Barrett's, Ulcerative Esophagitis, and a Hiatal Hernia. Doc put him on Nexium 40mg once a day. Which for the last 12 years he has been taking Prilosic which seemed to help til recently. I've heard alot of talk about a Nissen Fundopication. Does anyone know anything about this and how well the affects are? Will he still need medications? By the way, Doc did not even mention this procedure.
Any info would be great or links to anything that could help us with this.

Thanks,
Pattie Clio,MI