Reflux Query 2

[DTEG]

Hello again Doctor
Thank you firstly for your first response, that was very helpful. My doctor is now considering both the 24 PH test and an oesophageal barium test.  He has also asked my to try Prepulsid as he feels there may be some problems with stomach emptying and that may be contributing to the night time symptoms (see below).

I would like to describe the history of this condition in a bit more detail and would appreciate any further comments from your side.  

Initially (September 2003) I presented with stomach hyperacidity. I was also waking at night between 2 - 3pm with discomfort / pain in the upper right abdomen. I had persistent nausea during this time, for about 1.5 months.  I had an abdominal scan that showed no abnormalities of the liver or gall bladder.  I have not had any blood tests to date.

I was initially put onto Pariet and then Losec, neither of which did much for the symptoms.  In early November I went onto Nexium 40mg and had good relief of most symptoms for a two week period.  Then, the colonoscopy / endoscopy exam followed within the two weeks and after this I felt quite ill again.  I was told the bowel prep may have triggered this recurrence of symptoms.  As mentioned the colonoscopy was normal and endoscopy showed only mild gastritis.

Since the exam things have not resolved and the initial symptom profile has continued and in some respects I think worsened.  Initially I felt nauseous again and had a recurrence of the symptoms at night. The nausea settled down within about 3 weeks. As mentioned the throat related symptoms started about 3 weeks after the exam.  Currently I am still waking at night usually between 3 - 4pm, often with discomfort in the upper right abdomen, with stomach discomfort and now also burning in the throat.

At this stage I am sleeping in quite an elevated position and these symptoms recur despite this.  Sometimes there is a more severe 'attack' of these symptoms, eg I might wake up with breathing problems or severe nausea, and then will often feel quite ill until about lunchtime the next day.  

I guess I am concerned that if the reflux is allowed to continue then it will do damage to the esophagus.  Also not feeling generally well and having such a restricted diet is affecting my life quality.  I don't mind it for a period but need to know how much of this needs to be tolerated vs how much of it is unnecessary or harmful and needs a different solution.  

My doctor is also not in favour of any surgery, feeling it is too high risk and causes too many problems.  I have read about current minimally invasive procedures being used in the US including Enteryx and endoscopic surturing and am interested to hear your views on these.  I understand they are still in initial stages but are being used fairly widely or frequently in some places.

Once again your input is appreciated,
Regards
Sue I

[Kevin Pho, MD]

It is true that uncontrolled reflux may lead to a condition known as Barrett's esophagus.  This is a risk factor for esophageal cancer.  If the Nexium alone is not controlling your symptoms, you may want to consider an adjunctive medication, such as Zantac or Pepcid with the Nexium.

I agree that the 24-hr pH study should be considered.  If you continue to have reflux symptoms despite medication, then surgery is a possibility.  

Enteryx appears to lead to clinical improvement in up to 80 percent of patients with uncomplicated GERD whose symptoms had responded to a PPI. The mechanisms of benefit are unclear, since pH studies continued to be abnormal in many patients with a clinical response.

While the procedure appears to be generally safe, very few patients have been treated. Furthermore, the long-term efficacy is uncertain. Follow-up studies will help to clarify its role in the overall management of GERD in the context of other minimally invasive options that are currently available.

Regarding endoscopic suturing, there are a number of concerns in reviewing the outcomes of endoscopic sewing/plication therapies for gastroesophageal reflux disease. Most reported experiences have involved studies with small numbers of subjects, and issues of the importance of the learning curve have not been addressed.      Most of the suturing therapies are in clinical trials.  Studies of endoscopic sewing/plication have so far been mainly performed using subjects with mild, uncomplicated gastroesophageal reflux disease. Their role for symptomatic patients who have complicated GERD is unknown.

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.

Thanks,
Kevin, M.D.

Bibliography:
Bonis.  Enteryx™ for treatment of gastroesophageal reflux disease.  UptoDate, 2004.

Rothstein.  Endoscopic therapy for gastroesophageal reflux disease: Sewing/plication techniques.  UptoDate, 2004.

[JackieG]

Hi Sue:

I assume you are in the UK, given your spelling of oesophageal. I am a bit surprised that your GP is recommending Propulsid. It has been withdrawn in America due to heart-related side effects, including sudden cardiac death. A quick search of the Internet with the single word "propulsid" will reveal a number of notices for class action law suits stemming from the use of propulsid. Has your GP considered Reglan in stead of Propulsid?

I empathize with you regarding the way in which severe reflux disease compromises quality of life. There is also a real risk of oesophageal cancer as the result of prolonged GERD. If dietary and lifestyle changes do not provide relief from the reflux, you should consider surgery. Fundoplication can now be done laparoscopically, so the recovery time  is quicker and the risks are more manageable.

I hope Kevin is able to help you. You may also wish to get a second opinion from another GP or a specialist regarding the surgery.

Best wishes,
Chicken Soup

[tessa0825]

Hello, I just wanted to acknowledge you and hope you had a good holiday season and that you are still doing well? Tessa

[JackieG]

Thanks, Tessa. Good to hear from you.

I had my seventh or eighth surgery (I am starting to lose count) on 12/15/03, which went pretty well. I am hoping that I am done with surgery now. It spoiled the holidays, but all in all, I have no complaints. Life is good (and precious). I may not get the longevity that I would have preferred, but I sure am enjoying it while I have it.

Hope all is well with you.

Best regards,
Chicken Soup

[tessa0825]

Hi, well, this was not the outcome I was hoping to hear from you..Another surgery?...You would think after the big one you had that things would be better, assuming these are all esophageal related?....I wonder sometimes if any illness can be more frustrating than this one? Things seem to change at every EGD and just when you think you know what is going on, you realize its now all different...I remember when I actually had cancer in 95, wasn't near as nerve racking as this...Was very organized, I knew what was happening and what I needed to do to get well...Nothing like this...It still amazes me that people take reflux as something non-serious....My boss is a perfect example. he comes into one of our stores everyday and buys a king size hershey bar and a pack of rolaids...I have talked to him till I'm blue in the face, he just doesn't get it.... I will Pray that 2004 will be a good year for you....Take care, Tessa

[d97cards]

What is the feeling about the breathing connection with the refluxing?? Why would refluxung and breathing be connected?? Can I get comments here. My mom just had an egd and ultrasound, normal results, but she is taking Nexium and Pepcid AC, but  at night will wake up with a burning throat and shallow quick breathing. Water helps the burning.
Wonder would taking a liquid like Mylanta neutralize the acid that is still produced in spite of Nexium and Pepcid.
Thanks

[JackieG]

I don't know if the MD on site will respond to your question. They charge $15 for questions. However, I can tell you what the surgeon who did my esophagectomy told me about the relationship between breathing and reflux at night. He said that when I breathe at night it creats a slight negative pressure in my throat that makes it more likely for acid to come up into my throat. In my case, the acid sometimes goes down my windpipe (this is called aspiration), which is a very unpleasant esperience. It is important for me to be sure I don't eat or drink anything within three hours of going to bed and to sleep with the head of my bed elevated. I also take 40 mg Nexium twice per day.

Perhaps "Surgeon" will read your post and respond to you as well, as he or she is a Doctor and I am not.

Best wishes for your mother,

Chicken Soup