should i seek surgery?

i suffer from a chronic cough and constant upper chest pain. i am a 30 yr old male who has been through several medical exams: chest catskan-throat ultrasound and upper endoscopy. all exams were ok. after taking omepradex for two weeks- the cough stopped. the upper chest pain did not stop. the gasterologist diagnosed me w/gerd based on the fact that omepradex stopped my cough. i take 20mg. of omepradex twice a day. when i stopped omepradex  the cough returned. is surgery an option/recommended?d

[CalGal]

Elie, any doc who knows what they're doing will suggest you be on meds and control your diet for as long as possible before you even consider surgery. Surgery isn't a quick fix and it has a lot of side-effects that most don't talk about. It can also have some very undesirable consequences that you might not want to face.

Get back on the meds and consider a GERD diet.

[elie78]

my problem is that medication does not eliminate the chest pain. i've read about surgery and how it dramatically improved certain people. do you know anyone who has had surgery for gerd? please remember that i'm still young and don't want to suffer like this for the rest of my life.

[CalGal]

I understand that you're young, and it's one of the reasons I'm suggesting caution. The fundoplication surgery can have a a 'finite period' of time in some people in which it's effective. In some cases, the wrap can be re-done. But in others there are problems. One of them is that in doing the wrap, the esophagus is stretched - not a good thing. It changes the 'seal' effect that the upper stomach has between the thoracic cavity and the thoracic cavity. The pressures in the two cavities are very different and have to remain that way so that people can breathe correctly.

If the esoophagus stretches, the seal doesn't remain and it can cause breathing problems - in addition to the GERD reappearing. If the wrap has to be 'hiked up' toward the head in order to make it tighter, it can decrease the 'volume capacity' of the lungs = breathing problems.

So yes, the surgery can help, but at your age it's worrisome because there's no guarantee how long the wrap will last or what they can do if it fails - and you've got a lot of years left to enjoy of your life.

I think it's great that your asking for the experiences of others, but please don't jump into the surgery thinking it's going to fix everything.

Yes, I do know people who have had the surgery. And I've heard both sides of the story. It's one of the reasons I want people to really try to do everything they can before turning to the surgery, including looking into the endoscopic forms of intervention before going the Nissen route. Nissen can be great, but the longest I've heard of good results is about 10 years.

[elie78]

thanks for responding so quickly. i got the impression that you definitely know what your'e talking about. i will refer to surgery as a last measure. another question i would like to ask you: is there any examination that can 100% prove that my valve isn't fuctioning properly. the endoscopy that was performed on me was normal. the only reason my doctor diagnosed me w/esophogeal reflux is based on the fact that omepradex stopped my chronic cough. is there any chance that i don't have gerd?

[CalGal]

The endoscopy was completely normal? No gastritis? No changes in any way on the surface of the tissue? Did you actually read the doc's notes and any other paperwork? Most patients never see the reports, and I'd hate to tell you what can sometimes be found on there that you'll never hear about unless you get it and read it - so that would be my first suggestion. Get the records and read it.

If the endoscopy was normal, what other tests were done?

The other thing you'd have to look at is, is there no damage because it's too 'early' and no changes are apparent yet? And if so, is reflux happening - to check that you'd have to see if acid is coming up into the esophagus via pH monitoring. And you have two choices for that - a pH capsule or a dual ph monitoring which will check whether you might be refluxing acid or bile. That's a completely different 'critter' and can't be monitored via typical pH tests.

Another thing to check into - if you're NERD..........and no, that's not a comment on your intelligence. It means non-errosive reflux disease. What it means is that you could be reacting to your own 'normal' acid levels as if they're too high.

Did the endoscopy show any possibility that you have a hiatal hernia, even a little one?

Do you get a heck of a lot of mucus production in your throat, or post-nasal drip? Any food intolerance issues in your family? Any GI issues in your family? Just trying to cover all the bases...................

[boozer7daz]

you did not mention whether or not you are  over weight. I was diagnosed with barretts esophagus ..esophagitis and hiatal hernia.My docs put me on nexium and after 2 years and my second endoscopy ..was declared healthy.Weight can have a lot to do with these problems.. thats why I ask .I still cannot go more than a day without Nexium ...and still have the hernia. Nexium has changed everything for me and i highly reccomend it though others might disagree.Talk to your doctor it may work for you.Or change doctors for a second opinion.

[boozer7daz]

bye the way i am only 160 bls

[elie78]

again, thank you so much for responding so promptly. i was given a form that stated the results of the upper endoscopy.  the results were as follows:esophogus-normal throughout it's entire length. nothing was measured as abnormal. stomach -normal. based on the endoscopy i am healthy. the ppi's that i take stopped my chronic cough. the pain in my upper chest/lower neck was not relieved w/ppi's. when i stopped ppi's the cough returned after a week or two. when i started taking the ppi's cough stopped after a week. in my case, my physician diagnosed me based on the fact that the medicine helped my cough. i have an appointment w/gastro physician dec. 17th. do you reccommend ph monitoring or any other examinations to verify my gerd. thank you so much for your help.

[elie78]

no i am not overweight. i weigh 160lbs. as well and am 5'8". i am currently taking omepradex which is similar to nexium. tell me what your symptoms were like before nexium?

[ggreg]

Dear Elie,
This is a long shot, but I had a similar condition to yours and found out I was allergic to some pet rabbits I had.  Before I took allergy medicines, here is what I felt like:  I thought I was going to die, my chest was on fire, I coughed terrible, I was absolutely exhausted and in a lot of pain from all the coughing, and I was choking to death.  When the rabbits finally passed away, the symptoms went away, and I didn't have to take allergy medicine anymore.  So, I would suggest you ALSO look at that possibility, of having an allergy.  

There is ALSO a chance when the furnace comes on, it turns you into a coughing fool, and THAT will give you similar symptoms... the solution to that is get a humidifier for your bedroom and a little plastic gizmo from the hardware store to redirect the flow of heat away from your bed, change furnace filter regularly and keep your room dusted and vacuumed regularly.

By the way, if it's true you got acid boiling up in your tummy, for gosh sakes, it is NOT that hard to eat right, to prevent that!  Now, if you live on a farm and eat nothing but wholesome food and never eat out, and you have an active non-stress job, well, don't listen to me.  But the vast majority of acid reflux stuff is food-based.  In my opinion, all these drugs that people take are for much older people whose bodies have fallen apart, or ulceration (which you don't have) that has eaten away structures designed to keep acid in the tummy.  An occasional tums or alka seltzer is all fine and good, but the rest of it is treating symptoms and not the real problem.

All you have to do is a little research online for foods that cause acid.  That's it.  Quit eating them all, then add back, one at a time, the stuff you think you can't life without.  Plus don't eat at fast-food places, don't eat out very often and only at places that don't upset your tummy, don't eat fried foods, don't eat too much meat, and don't hurry thru your meals.  But DO eat a lot of whole wheat and oat products and salads and a small glass of juice and colorful vegies.  PLENTY of water and daily exercise also are part of this "special diet" you are resisting, as well as eating at least three times a day.

One other thing I might mention is, over-the-counter allergy stuff won't work.  Now, my doctor was first-rate, he was an excellent diagnostician, so he knew instantly what my big problem was.  And I didn't have to undergo a single test.  I would suggest, therefore, if you are willing to consider allergy, is you go visit an allergist's office, tell them your story, and let them have a go at you.  In the meantime, just give wholesome eating habits a try for a couple weeks, as I have described above, and just see if it helps at all.
GG

[elie78]

greg, thanks for the tip. i actually eat healthy most of the time. i'm also not that enthusiastic of taking medicine at the age of 30. the problem is that my cough is unbearable if i stop the medicine. as far as pets are concerned- i don't have any. i live in a warm climate area so heat is not the cause. maybe i'm allergic to something else? i'll give the allergy doc a shot.

[blueman22]

Chronic cough is definitely related to acid reflux or GERD - I have the same problem. It occurs due to a weak valve at the top of the stomach that allows acid into the esophogus when you sleep. Taking a proton pump inhibitor like nexium - which stops acid production in the stomach - does help to stop or reduce the cough and usually reduces stomach or chest pain. You might have to take them for longer than 2 weeks for your body to totally adapt to the medication. The  ironical thing about the PPI's is that sometimes the side effects mimic the symptoms. I took one drug in the family that actually caused severe chest pain - when I switched to a different PPI the pain disappeared. Another thing you can try is raising the head of your bed 6-8 inches - this keeps the acid from entering the esophogus at night and reduces or stops the coughing. Diet is also important. Cut out things such as coffee, citrus fruits, tomatos, alcohol etc. that irritate the stomach and/or cause excess acid production. If you go to the Mayo Clinic website and look at the GERD topic they give quite a lot of information on the problem and its treatment - including surgeries. (I certainly agree with CalGal on the surgery option - they don't always work and should be considered as a last resort.)

[elie78]

let me clear things up. i have been taking the ppi's since april 2008. i have tried 3 different ppi's as a matter of a fact. the chest pain/lower neck does not worsen after eating and is constant. is there any exam that can 100% verify that the valve is in fact weak? maybe the ppi's stop the cough as a side effect. i'm not 100% sure that i have gerd-how can i verify for sure?

[elie78]

do you know which exam can verify the valve being weak? i have a gatro appointment for dec 17?

[elie78]

are there any reccomendations for my gastro appointment dec 17th?

[CalGal]

Elie, if you're experiencing something like NERD, there's no test that's going to give you a definitive answer that the cough is linked to your body's reacting to your normal level of acid production as if it's too much. You can only go by the evidence you finding: start PPIs = stop cough.

If this is caused by true acid reflux, but you just are 'touchy' to the acid and it's too soon to see any damage, the only way to see would be to wait and redo an EGE in a year or so and recheck.

There's unfortunately nothing wonderfully specific - unelss it's damage that's visible - to be able to find out whether you've got GERD.

The most obvious changes that go on with 'aspiration GERD' is the development of 'webbing' or changes in the trachea over a period of time, but it's something that can take some time to develop in many people.

I wish I could give you some definitive things to ask for, but I think you are doing a lot of the 'testing' yourself at this point.

As far as the LES being leaky, unless it's a full-blown hernia, or a sliding hernia that they can provoke into sliding  and 'catch' it on a barium swallow, then no. The LES is actually a 'ring' of tighter muscles at the lower end of the esophagus. It's 'reinforced' from the outside by the placement of the leaves of the diaphragm and a 'strangely' placed ligament called the phrenoesophageal ligament. If the ligament starts to stretch, it allows the diaphragmatic leaves to 'loosen' their reinforcement because the leaves move (typically downward) - so now they're below the ring of muscle. That ring of muscle can still 'look' normal from the inside during and EGD. However, since the pressure on it isn't as great at that point, when to top of the stomach expands duing food intake, the reflexive response to 'accomodation' allows that 'ring' to more easily open (pressure from below - the stomach - will then be higher than pressure from above - the esophagus) and it opens allowing food and acid to go upward.

So unless you're at the stage that you have an actual 'always' looser LES, it's difficult to see. But docs will typically try to provoke a sliding hernia out of hiding during a scoping -- you might want to ask the doc if any small changes indicating a hernia were found. Sometimes the results on paper don't give you the whole story.

[coughting]

Elie, I also had cough related to reflux.  The cough was not constant but came and went.  Last March I had a 2 1/2 week episode of coughing and told my gi dr that I could not live this way (my blood pressure spiked and my gp dr told me he tought it was because I was getting so little sleep with the coughing).  My gi dr sent me for tests and one of these was the 24 hr tube down the nose that tested for the level of acid.  This test I pressed certain buttons, when I ate, coughed, slept etc.  The test did show that the cough was happening after the acid reflux.  I didn't have heartburn, just coughing.  I had the Nissen done in Oct. and so far so good.  I still cough some but nothing like it was and not coughing up all the gunk at night and having to sit up for 30 min to hr before I could go back to bed.  Often a cough is caused by several different things.  I also had lung tests before my surgery and they came out fine.  Just make sure that you have the best bariatric surgeon around.  Mine did a loose wrap and I am able to burp etc.  I think the rest of my coughing is allergy.  But like I said it is completely different and not causing the damage to esphagus that happened before.  Good luck

[elie78]

i want to thank you gain for all the information. my guess is that you are in the medical field. if it's ok w/you i'll get back to you after mmy appointment dec. 17. all the info has definitely educated me-thanks-elie

[CalGal]

No problem, Elie. And keep in mind that the others who have posted have had experience with this problem so their comments are on-the-mark. I know you don't want to take meds - I don't think a lot of people do - but there are times that it's almost unavoidable.

Also, check to see if anyone in your family has any food intolerance issues. As strange as it sounds, people do react to foods in varying ways. With some there are very apparent fatigue, rashes, diarrhea, constipation, etc. But you can also respond with a slightly different response such as post-nasal drip and/or coughing. You may want to consider some 'food challenges' - take out a food group, wait for a week or so, and then re-introduce and see what happens. If you see even the slightly change (an I mean it could be REALLY slight), then delete that food group for several week and wait.

Even if relatives don't confess to any food issues, keep a food diary and note everything you feel - even the slightest things. You might find a pattern.

In this day-and-age, despite all of our very 'sophisticated' medical tests and treatments, we're really just starting to understand what goes on with the human body. Some of the 'figuring things out' has to rest with the person having the problem. So do some self-testing' while your doc is trying to do his side of the testing equation.

[elie78]

hi- i was wondering how old u r? r u still taking medication after surgery? did the surgery eliminate your cough? thanks-elie

[elie78]

hello again! i went to the my gastro physician and as follows:
1. there is no evidence that i have gerd based on the endoscopy
2. i schedueled ph monitoring + x-ray of the digestive track
3. he prescribed new meds: rantidine-the result after taking for 4 days- my cough returned and i'm back on ppi's=omepradex
any comments?

[CalGal]

Elie, the pH monitoring is a good idea. Since the endoscopy didn't show any damage, the next should be to double-check and find out if you are refluxing into the esophagus despite not seeing any outward signs. Did they do a biopsy of the esophagus, stomach and duodenum to see if anything was going on under the surface?

Rantidine is a specific form of histamine blocker. In the stomach histamine acts as a hormone that upregulates the acid producing cells. I believe it controls about 1/4 to 1/3 of the acid production in the stomach. The histamine blockers are typically a med that works for about 24 hours or less, and their use doesn't build up acid suppression as PPIs do. Overall, they may not be as effective in some people as PPIs are, but it may also depend on the dose.

With the return of your symptoms, it sounds like acid reflux of some sort.

[elie78]

hi, it's been a long time. unfortunately i'm suffering. i have news. unfortunately it takes time to schedule med examinations. i am scheduled for ph monitoring on february 25th. meanwhile i had another x-ray of the digestive track. the result is : mild pressure to the medial esophagus most probably represent prominent aortic arch.
esophageal reflux up to the cricopharigeal region. no evidence of hernia, filling defect. so now it's certain that i have reflux.
my questions are as follows: should i still do the ph monitoring?
if i take ppi's why am i still refluxing, especially after fasting for 12 hours prior to x-ray?
the pressure to the esophagus is resulting because of reflux?

[CalGal]

Elie, if your doc accepts the results of the x-ray - that you've got reflux up into the throat - you may not have to do the pH monitoring. The best thing to do is call and ask if you're unsure that you want to do it. But if you're going to consider doing the surgery, I believe the doc will require a pH montoring. He should also require an esophageal manometry, too, just to make sure that there isn't anything wrong with your esophagus. If there is, and surgery is done, the results may be way less than optimal, or muscular issues could make your life less than optimal in the long run.

But this result is in direct contrast to your EGD - which said there was no evidence of reflux, right? So the doc may require a pH test for clarification and to differentiate between several options such as GERD or NERD, etc.

There are, unfortunately, a lot of people who continue to reflux even when they're taking max doses of PPIs and no one has an answer for that yet. I wish I could answer that for you, but anything I could say would be pure guessing.

According to your written results, the pressure is being placed on your esophagus because of your aortic arch. That's the 'branching' off of your heart of the main blood flow channel (the aorta). One branch supplies the blood for the upper extremities, and the other branch heads 'downward' into the body to supply the rest of the body. Evidently yours is suggested to be 'poking' into your esophagus somewhat.

[coughting]

I am 62 and only started have problems in 2000.  Sorry it has taken so long to get back here.  I never had heart burn only the cough with lots of mucus.  I had many many tests and finally told my gastro dr that I could no longer live this way.  I had the ph montering test and it showed that I had reflux. If the PH test show reflux it means you have a week valve.  When i went to the surgeon he said he thought I probably had a hiatial hernia.  After the Nissen he told me I did have the hernia.  This could be causing your pain.  I also and the endocopy which did not show any problems.
This was caused by the fact that I did not have any scarring etc. at that time.  But i can tell you that the cough was so bad I would have had.  My surgery was last Oct.  No I am no longer on any meds and have no reflux.  The only bad thing is that i have gas often at night.  but I can live with this...  gasex works.  The meds for reflux did not stop my cough.
Have you had your other test yet?  I even went to a lung dr to check out my lungs before I had the Nissen.  My Gastro dr was not really for my having the Nissen because he never was convinced that the cough was from reflux.  However, he now sees how great I am doing and is happy for me.  If you have the surgery ask for a loose wrap.  Gone for the day but will look at this site tomorrow.

[elie78]

thanks for responding, you are a rare statistic- because most people do not reccommend surgery. was the procedure difficult? how long were you hospitalized? what were your conflicts between having the nissen or not? thanks!

[elie78]

you are truly a big help! i will update you after the ph monitoring and esophageal manometry. thank you again and again! i will definitely consult with you after exams on february 25th.

[coughting]

I was in the hospital only 1 day and night and back to work the next week.  
I had read all the horror stories about the nissen and not being able to swallow etc.  But the coughing was causing me load of problems including high blood pressure.  I had coughed for 8 years and it was getting better.  Meds did not help.

I did have to press the gastro dr and tell him that I could not live this way any longer.  I saw the surgeon before a lot of my tests.  I just made the appointment it was the same bariatric surgeon that did my bowel resection and I knew how good he was.  He said that he would want all the test done before he would consider the surgery.  I had the test done including going to a lung dr. to rule that out.  My gastro dr finally said go for it but he was not sure it would help.  
I went back to the surgeon and he said he could offer me a loose wrap.
He was very confident that it would solve my reflux and with the loose wrap I would not have any problems.

Let me tell you it was well worth it.  But again make sure you get the best bariatric surgeon around.   I think a lot of the problems people have had is the surgeon.

[coughting]

sorry when I said I had coughed for 8 years and it was getting better, I should have said it was not getting better.