reflux and lifestyle expectations

[michele__0__0]

  I have over the last 5 to 6 years noted some increased problems with heartburn.  I also knew that I could bend over and have stomach acid wash into my mouth.  Then over the last year I began to have a significant increase in my asthma symtoms and would keep a chonic cough with fequent bouts of sinusitis and bronchits.  I also developed migraines that would usually occur at 6:30 or 11:30 in the am.  These always occured after a particually restless night.  my husband had noted some odd breathing vs choking noises on these nights before the migraines.  I was tried on numerous medicines to control them but nothing helped and I was have 9 to 10 per month, with daily headaches in between.  I also was taking motrin and wigrain to try and control the symtoms. In April of this year I was having such bad heart burn and migraines that I was waking up hourly for  nights in a row.  On the way back from our trip I had an asthma attack and ended up in the  ER with bronchits and then in my asthma allergist office the next day for iv steriods.  I then developed bouts of tachycardia and anexity that seemed to be associated with lying down and eating.  My physician and I thought at the time it was related to the Biaxin and Desimpraime combination. I stoped the desimpraime and   these spells gradually improved , but then I developed such bad stomach pain that I was unable to eat and started to lose weight.  I had a barium swallow looking for ulcer disease and found severe reflux with a patulous esophagus and esophagitis.  I was placed on prevacid 30mg.   I had gradual improvement with the stomach pain and with my asthma.  My migraines and daily headaches are gone. I also have been bronchitis and sinusitis free for 4 months which is a record time period for me.  I still continued to have reflux and esophagistis symtoms.  I have elevated my bed on 6 inch blocks and have followed the dietary recommendations .  I feel symtoms of reflux with fatty foods, diary, fruits and certainly spicy foods.I do not drink coffee or alcohol any more.  I feel that my diet is severly restricted particually with the diary and fruit limits.  I have lost 11 pounds with out trying and cannot afford to take off much more weight for my body frame.  I was sent to a G.I. doctor who increased my prevacid to 30 mg 2x a day and increased my propulsid to 20 mg at night.  He wanted me to take it 2x a day , but I find if makes me feel very tense and nervous and even the 20 mg at night time gives me strange dreams while if i decrease it to 10 mg I don't have those side effects.   I had improvement with my symtoms but not what I would consider optimal improvement.   I went in for a endoscopy by the g.i. doctor and was found to have some mild esophagits still.  My stomach was fine and there was not evidence of a Barretts esophagus.  The biopsy's are pending .  He felt that my dysphagia was related to some esophageal spasm and edema.  Recommendations are to continue on the 2x a day prevacid 30mg and proplusid for another month which would give me 7 weeks of 60mg a day of prevacid and a total to 6 months of therapy. and then see if it is possible to wean the medications. I am not sure at this point what to consider maximal treatment.  I would have expected all esophagitis to be healed with 5 months of therapy.  I have been told that I will be obligated to medication for a lifetime.  Considering that I am 38 years old  and am having to take 5 medications a day I find this depresssing. I am on azmacort, ventolin, prevacid, proplusid and Nasonex in additon to allergy shots. I have had alot of improvement over the last 6 months illness fequency and the migraines going away.  How long should I give myself to heal before you consider surgery options.  My G.I. doctor has already mentioned this to.  How successful is the surgery and what type complications are common.?  I don't want to rush into surgery.  I also realize if I chose surgery that I will still have a degree of asthma due to my allergies.  It has amazed me how much my peak flows increased once I started on the prevacid. and proplusid.  I increased from max of 450 to 550 -600 on good. days.  Are there any guidelines that you do 'a' for 5 months then proceed to "b"  for 5 months  and if these fail then the patient is a surgical canadit.,  I appreciate your  time  and comments.  
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Dear Michelle and other rspondents,
The symptoms described in Michelle's letter are common presentations of esophageal reflux and esophagitis.  In particular, the asthma and bronchitis are exacerabted by reflux.  other extra-esophageal presentationd for esophageal reflux include laryngitis, sinusitis and dental cavities.
The cause of esophageal reflux is a motor abnormality of the esophagus- a low or inappropriately relaxed esophageal sphincter.  the symptoms, however, are related to the reflux of acid and pepsin, a digestive enzyme.
You are correct that the problem is lifelong although the severity of symptoms may vary.  Medical tretament includes elimination of factors that lower the esophageal sphincter pressure (e.g. fats, peppermint, chocolate, alcohol, cigarettes), stimulation of saliva production by chewing gum or sucking candies, inhibition of acid secretion ( in your case by the use of potent proton pump inhibitors) and the use of drugs that promote gastric emptying and increased esophageal pressure, to reduce the amount of acid available for reflux (Propulsidis used to enhance gastric emptying).
Some patients do not respond to maximal medical therapy and others do not want to take medications forever.  For these individuals laparoscopic Nissen fundoplication is an attractive alternative.  the surgery is done with a small incision so the rucuperation period is relatively brief.  The most frequent complications of surgery are an inability to belch (associated with bloating and gas) and occasionally difficulty swallowing, if the surgical wrap is too right.  Before you could be considered a candidate for surgery, your doctors need to do a motility study and 24 hr pG probe to veerify that you have normal esophageal motor function (important to reduce the risk of difficulty swallowing  after surgery) and a 24 hr pH probe.
This information is presented for educational purposes only.  Always ask specific questions to your personal physician.  
If you wish a second opinion, we wouild be happy to see you in the Division of Gastroenterology at Henry Ford Health System.  You can arrange an appoinment with Dr. Fogel, one of our experts in the diagnosis and treament of esophageal disease, by calling our Physician Referral Line at [phone].  After a review of your prior evaluation, he can suggest next steps.
HFHSM.D.-rf
*keywords: esophageal reflux
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