Reflux on medications??

[wilkat]

I have had GERD for several years, but it was fairly well under control with prilosec until this year. On my first endoscopy in 1997 I had grade II esophagitis and scarring in my stomach.  That was before I started any proton pump inhibitors.  I started on Prevacid and still had some burning, but not that bad. Recently,  after having to be on several antibiotics and then prednisone for several months for respiratory problems,  I had to start taking 2 nexiums.  I had an endoscopy in September and biopsies showed acute antral  gastritis and chronic superficial gastritis in the fundus even on the 2 nexiums, but the esophagus was OK.   There was also duodenitis.   I  did not have H. pylori.  I  had a normal barium swallow, but it  showed wall thickening, mucosal irregularity and a filling defect along the  stomach walls;  there was some retained food, but no mass.  The doctor said that I produced too much stomach acid.   The day after the endoscopy I had severe burning pain that went from my chest to my back and lasted all day.  I ended up in the ER thinking I was having a heart attack.  My heart was OK and I didn't have any more of this pain until about 6 weeks ago;   it actually began as I was tapering off of prednisone.   I was back at the ER twice in 3 days for the severe pain.  I added tums and  GI cocktail without relief.  I was up and down most of the night for about 3 weeks.  I would try to go to sleep and  wake up every hour or so with a strange noise in my throat and could feel the stuff coming up and burning my esophagus and throat.  My teeth are also extremely sensitive and I've had mucus in my throat.  I finally had a pH probe (was on 3 nexiums, pepcids, tums, and GI cocktail)  that came saying I had excellent acid control;  my stomach only had a pH below 4 10 % of the time, and the proximal chanel only .7% of the time, but I did have 39 episodes of reflux, all less than a minute and 281 in the stomach???  Before this final reading had come back,  the GI doctor had looked at the meter and said I had several low readings and put me on 2 protonix twice a day and asked me which surgeon I wanted to see and even made an appointment.   The surgeon was waiting on the motility report (which apparently I didn't have) before he would do surgery.  In the meantime I had an appointment with  GI doctor last week and he didn't even remember talking to me and says this could not all be reflux if I'm still having problems on that much medicine, and now says I would not be a good candidate for surgery. But he has told me to continue taking the 4 protonix  and  2 pepcids.   I am sleeping most of the night now.  The pain is not as bad as it was, but is still bad at times. It will let up for a couple of days, but then it comes back. I'm not taking the antiacids as much now.  

1.  Is it possible that I had several major reflux expisodes before going on this much med that injured my
     esophagus and now even a little reflux makes it hurt or that it just still hurts from the original damage?
2.  Considering I was on that much medication when the pH probe was done, is the test reliable (I was told to
     have it done on meds)?
3.  If this isn't reflux, what else could it be?
4.  Is it possible that this will improve as I go off the prednisone?
5.  Isn't it harmful to be taking all of this medication?
6.  What would make one not a good candidate for the surgery?

[Kevin Pho, MD]

To answer your questions:
1) It is possible that the prior reflux could have increased the sensitivit of the esophagus, thus amplifying the symptoms of small amounts of reflux.

2) The pH probe is typically done off medications, however since you continued to have reflux despite medications it suggests that  the amount of reflux is severe.  

3) GERD, ulcers, gastritis/esophagitis/duodenitis, and H Pylori are all considerations.  They have already been tested for.  With a positive pH test, GERD is still the most likely cause.  Evaluation for a hiatal hernia can also be considered.

4) Yes, prednisone can exacerbate upper GI symptoms, and it is possible that the symptoms may improve off prednisone.

5) In general, PPIs are safe medications - however taking that much of it on an extended period of time has not been studied in long-term trials.  Ensure you are receiving close followup while on this doseage of medication.

6) Your surgeon is correct in waiting for esophageal motility tests.  Esophageal motility causes, such as scleroderma and achalasia will not make one a good candidate for surgery.  

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.

[gerd]

Just looking at my 24hr ph test, it says a"normal" reading is a PH below 4 less than 4% of the time.  You state that yours was a
pH below 4 -10 % of the time. I to was significantly worse after my scope - I think it irritates some of us.  Even though my symptoms are a little better than when I first got the reflux, my esophageal pain is now more intense, I beleive all the reflux over a long period of time takes it toll...

Get a second opionon if you are not satisfied, my original GI told me that "nothing" was wrong with me even though I have a very weak valve, severe gastritis in the stomach and esophageas.
Now 2 other doctors are helping me as they see a problem...

[wilkat]

Thanks for your comments.  The 10 % was in my stomach which means that the acid was 90 % suppressed which I guess is good.  The proximal channel was in the esophagus and only had .7 % which is quite low.  It seems like on that much medication that it shouldn't have had that many episodes of reflux though.  The GI doctor has said I could have laryngeal esophageal reflux that wouldn't show on this probe.

BTW, I forgot to mention in my post that this couldn't be my gallbladder because I had it taken out, but I have wondered if it could be bile reflux.

[yoshi]

yes.all that medication has side effects,read the label and see how much chemical there is-aluminium,magnesium,sodium.
do you have constipation or diarhea (diarrhea)??

[tessa0825]

He is right about the LPR, it requires a double probe test but for the acid to reach your throat and vocal cords it has to  reach your esophagus first..I don't think 36 episodes in 24 hrs. lasting less 1 minute each is very significant..Im basing that solely on my reports and what my surgeon has told me about reflux..He says people who dont have reflux disease can reflux up to 50 times in a 24 hr period and it be normal....As important as the number of episodes is the length of time they last...My report and Dr. stated I was refluxing almost non-stop but I only had 78 episodes in the 24 hrs. however my longest episode was 83.6 minutes...It becomes the combination of information these test provide that tell the story...As for being on PPIs during the test, your right, it usually isn't done that way..Most drs. require you be off meds for 5-7 days before testing.....He could have been testing you though to see if the meds were working,in that case he would have wanted you to continue meds...

[tessa0825]

I also wanted to tell you that I also take Prednisone as well as injections of methotrexate and the gastritis and problems from that is pretty bad most of the time...I think as long as we are on these type meds we are certain to have GI problems..My GI Spec. recently put me on bentyl capsules for the GI spasms and cramping..It so far has been better...I started taking 10mg 4 times daily of bentyl and am now taking 20mg 4 times a day...I talked to him this week and will see him next week and discuss rather we will raise the bentyl dose again and evaluate if I should even continue it or not....I also take Zelnorm to help with the motility in my esophagus and GI system....Some Drs. say the best candidates for fundoplication (reflux)surgery are the ones who respond the best to medication treatment.....Having this surgery requires alot of pre-surgery evaluation and testing, usually PH probe to evaluate reflux, manometry to make sure you have enough motility in your esophagus to allow surgery because you will have some swallowing difficulties following surgery, and usually an EGD to evaluate the health of your esophagus...I had fundoplication surgery combined with an esophageal lengthening surgery in Sept 2003, Im still refluxing, back on the GERD diet, still taking nexium twice a day and have new esophagitis since surgery....My expectations may have been to high as my esophagus was very damaged...I have talked to many people who since surgery are reflux and meds free and having no problems at all....Good luck with this, I hope you get better soon....Tessa

[eeprete]

Wow, all I can say is I am learning a lot here.

I have had LPR for several years now. My ear nose and throat specialist said it's possible my post nasal drip is playing a role in it all too. Do you have allergies? You seem to be on lots of meds that don't seem to be helping. Lately (past two weeks or so), I have been having many of these same symptoms. Last night was actually the worst of them all. I only got a total of 3 hours sleep and I am sitting here on my couch with a pounding headache because of all the coughing all night. It reached a point a few times where I couldn't even breathe.

My ENT doc prescribed zyrtec which seemed to help for a while, however I like you are finding horrible nights of sleeping and endless hoarseness. I will sometimes have to doze at work, just to keep going through the day.

I am also on nexium and have been for the past few months. That too helped initially but seems to have worn off its effects. I am also on a low residue diet, or which I have cheated once or twice having a chocolate muffin in the morning (BAD BAD move). I am considering stopping the nexium and going the route of prilosec which I took for about 10 years and it always helped. I also found Aciphex made it worse when my doc prescribed that.

I recently had an upper GI done, but am waiting on the test results. what makes my matter worse is that my stomach doesn't sit properly (the entry and junctions sit at almost the same height and my stomach is shaped like a valley). Because I was born without an esophogus corrective surgey is a dangerous consideration.

Has anyone had experience with foods making the reflux better when having an attack? I keep dry cake and sugar wafers around and those seem to help a little but not a lot (My idea is that I hope it absorbs some of the acid going down).

[eeprete]

one other thing I forgot to mention.

have you adjusted your sleeping position at all? I have been sleeping with a wedge for a couple of years. it helps a little, but lately I have had to also use about 5 extra pillows. I am sleeping in almost an upright position now.

[wilkat]

Thanks for the information.  I'm sorry you are still having problems.  I am scheduled for the manometry next week.  I probably should not have taken all the antacids with the pH probe, but I had to wait so long to get it I was in severe pain before I even had it.  Since I was still symptomatic on 2 nexiums I was supposed to stay on them, but I don't think I was supposed to take the other stuff.   I think the probe irritated my esophagus so that may have made the pain not correlate to the reflux episodes.  I know I was having bad reflux because I could feel it coming up and burning.  I think for some reason the regular probe doesn't always pick up the LER.  I know it doesn't make sense since it does have to come up the esophagus, but maybe it's so fast it doesn't pick it up.  I just know my GI doctor said I could still have that kind of reflux and the upper probe would detect it.  I am tapering off the prednisone and hope that will help.  I also had a chronic mold exposure at work from a mold that produces potent toxins and don't know how much that is contributing to the problems.  

[eeprete]

wilkat, strange enough I have a mold issue in my kitchen that has yet to get resolved by my condo complex. I wonder if that is playing a role as well. I had though the same thing. maybe ask the GI doc. I do know mold can significantly affect allergies and such.

[yoshi]

i dont know of any food which helps when one is having an attack,but mylanta and galvescan provide quick relief.
and if you are lying down when it happens,sit up or standing up help.

[wilkat]

I mentioned the mold to the GI doctor and he just said he didn't know a lot about it. The particular mold that I was exposed to was Fusarium and I had elevated blood antibodies to it and T-2 toxin that it produces.  If you look that up on the internet it brings up biological warfare and it mainly affects the digestive system. I had to quit my job because of severe respiratory symptoms that I developed after the exposure.  I do have post nasal drip and have had the Fusarium and a couple of other molds I have been exposed to cultured from the drainage.  I don't know if this is contributing to the problem.  I'm not allergic to the molds, but show Igg responses to them. Antibhistimines don't work.  I'm trying to get a doctor to give me a nebulized antifungal, because I can't take anything orally now, my digestive system is so bad.  I've tried a couple of times and I get the severe burning chest pain.  I do use nasoex and do saline nasal rinses several times a day.  I get a lot of mucus in my throat so I don't know if that is form the drainage or from LER.   I was half sitting up sleeping when I had most of my attacks. They would wake me up.  I'm really concerned about taking this much medicine and it still not completely working although I'm not in the severe pain that I was in.  I really don't know what to do.

[yoshi]

you better look up on antihistamine.
histamine is produced by the body to fight micro organisms taken in from the air,too much antihistamine suppresses the body from producing histamine.
i took it for too long(read the labels and it mentioned some side effects like narrowing of passages of esophagus and intestine,headaches),i have all these symptoms plus i was getting weak like i was having respiratory problem esp in the morning and my finger knuckles start to swell like in arthritis.
once i stop taking it,all these symptoms go away.
read about antihistamine and role of histamine in your body.

[jaspur]

Sounds like reflux. I had the surgery done in 1995 and do not get any acid coming up as long as I take the medication. If I eat badly I will get chest pains.Check the question in this forum 3/4/04 Nexium and polyps.