GERD and Asthma

[benderbabe]

My husband had a barium swallow and endoscopy after presenting with suspected GERD symptoms about 5 years ago, which returned a positive result.

He has been taking losec (omeprazole) twice a day (AM/PM) for the past 5 years, and that has seemed to control the symptoms.

In the past 3 years or so, he has increasingly had asthma symptoms. They are not severe, but he sometimes uses an inhaler (non-steroidal) when symptoms are bad...maybe twice a month).

About a year ago, he had two herniated disks, which cause him great pain.  With reluctance, he began taking Celebrex (not good with omeprazole, I understand), which helps greatly with the back pain, along with his physio.

Now that he has taken Celebrex for about 8 or 9 months, the asthma seems to be getting worse, appearing mainly at night, with wheezing, and a spell of coughing in the morning which usualy produces mucous, and thereafter the asthma symptoms cease for the day.

He also has coughing, throat clearing, upper back pain (but rarely heartburn), and occasional coughing after meals.

After reading more about GERD and relation to Asthma, I have insisted that he sleep with his bed head elevated 6 inches, which is reducing the asthma slightly (his specialist insists that sleeping elevated won't help GERD..not what I have heard).

Life is pretty unbearable for him without the celebres, so what to do?

In addition to all this, we have owned a pet bird (cockatoo) for 10 years...

He is going back to see his specialist and revisit his treatment options later this week, but a second opinion is always good, so I have the following questions:

1. Is it likely that the bird is causing the asthma and that is making his GERD worse (he was not asthmatic for the first 4 years we owned the bird at all, but was somewhat as a child when he owned a dog).  Should he be tested for such allergies?

2. If his asthma is worst at night and appears SOMETIMES after meals, what is the best treatment option?  Is the omeprazole he is taking the best option in this case? (I have heard that the newer motility drugs plus H2 blockers at night might be preferred in such cases)

3. How important is losing weight (he's fairly overweight) to effective treatment of GERD? (Food is his life, he says it will kill him to have to eat a bland diet, and quit coffee...only 1 cup a day in the morning).

4. I have heard of some new treatments that are less invasive than the surgery for correcting GERD, which relate to suturing or burning the sphincter muscle.  Are these treatments currently recommended, and if so, how successful are they?

My husband seems to be one of those unlucky people with chronic symptoms which are hard to treat with medication, so any advice you can give on last ditch attempts before considering surgery are appreciated.  

I suppose that the tests his specialist will undoubtedly send him for next week will tell us if the condition is worsening or not, anyway.

Appreciate your help.

[JackieG]

Hi Benderbabe:

Hope you haven't left this site. Here are the recommendations for Sydney surgeons. The come from the Chief Medical Officer and Head of Surgical Oncology at the Peter MacCallum Cancer Institute in Melbourne, which is arguably Australia's leading cancer center. While your husband may not need their services if he elects not to consider surgery, a consult with their offices to find out what GI docs they recommend should be useful. The best surgeons generally use/recommend the best GI docs.  

The recommendations are:

Phil Crowe, Associate Professor in the Department of Surgery at the Prince of Wales Hospital in Randwick, and

Dr. Thomas Hugh at Royal North Shore Hospital Upper Gastrointestinal Surgery Unit.

Hope this helps. Let me know if you recieve this information and also let me know if you want to get in touch with the EC Support Group in Sydney (see my previous post just above this one).

Best regards, and hope to hear back from you.

Chicken Soup

[JackieG]

Hi Benderbabe:

I spoke by email to two of my friends in my Internet-based esophageal cancer support group. One has offered to ask his GI doc for referrals in Sydney (this person is in Melbourne), but his doc is away from the office right now (sounded like vacation), so it may be several weeks before I hear back.

The other friend is in Sydney and is a member of a small Sydney-based esophageal cancer support group. They have offered to correspond with you by telephone or email if you would like. I know your husband does not have EC, but these folks have used GI docs in your city, as well as surgeons, so they will have personal experience with local GI docs.  Let me know if you are interested in getting in touch personally with the Sydney EC support group by posting "yes" or "no" as a reply to this posting. If you say yes, I'll post my private email address so you can contact me directly, and I can put you in touch with the Sydney suoport group. If you say no, I won't post my private email address. In either event, I will post again with the names of GI doc recommendationsonce once I have heard from the Melbourne contact for GI docs in Sydney.

How did the most recent doctor's appointment go?

Thanks,
Chicken Soup

[karyzma]

I have asthma and GERD.  I am on Advair, Singulair and Combivent.  It seems when my GERD is out of control my medications and even my inhaler do not work as well.  Are medications not as effective for GERD-induced asthma?  

Thanks for all the help you give to everyone on this forum.

[JackieG]

I have asked my Australian EC friends for recommendations for both gastroenterologists and laparoscopic surgeons in Sydney. We have over a dozen Australian members in the EC Support Group I am in, but I am not sure how many are in Sydney. It may take a couple of days to get referrals. Please check back for a later post on this site if I come up with names.

Best regards,
Chicken Soup

[benderbabe]

Thanks for all your help guys.  I appreciate it, and will continue to check back, and will report on how my husband is doing in case your'e curious!

Thanks for describing your situation, Tessa.  Actually, most of the info I have read online about the surgery has been positive, and MOST people I have encountered seem satisfied enough with the results that they say they would do it again.

I personally have a phobia for surgery of any kind that is remotely invasive (had a d&c this year, and the stress leading up to it nearly killed me), but my husband is not as freaked out by stuff, and doesn't like the lifestyle change inconveniences...so he may very well turn out to be a candidate for surgery. We shall see.

The really good news is that my husband is FINALLY getting used to sleeping with the head of the bed elevated...he hasn't complained of the back aches as much in the past few days.

Tomorrow is his appointment with his specialist, so I assume tests will follow before we know anything concrete.

[tessa0825]

Hello,
I think, personally, that under the right circumstances, and with the right surgeon fundoplication would certainly get my vote over the other less invasive procedures..There is not enough information on them yet. People that have had some of those procedures, don't seem to be that happy..

I know you are wanting my experience with fundoplication...I had a very experienced surgeon at one of the top hosp. in the states. My condition is complicated by Barrett's esophagus with dysplasia and even worse by a systemic illness that causes fibrosis (scarring within my organs) I had alot of problems with a stricture prior to surgery and a part of my surgery was to lengthen the esophagus because of the stricture and because I had a very large hiatal hernia....My surgery was a pretty big complicated one..I was home within 5 days and went back to work at 5 weeks....I have since retired from work..

As far as the fundoplication part of my surgery, Yes I would have it again, I would have the entire surgery again...It didn't do everything I had hoped it would do but my esophagus is in better shape now than it was before surgery...I still take nexium, but at a lower dose and I still follow the GERD diet...AND I STILL SLEEP WITH THE HEAD OF OUR BED ELEVATED!

The normal for laproscopic fundo surgery seems to be that people are coming home after just one nite in the hosp. and many are returning to work within 2 weeks with some lifting restrictions...Most don't have to take anti-reflux drugs again and can gadually begin adding many foods they had given up back into their diets....I would think the time to have this surgery would be at a time before serious complications occur...You can have all the surgery available but once you get Barrett's esophagus you still have Barrett's esophagus and continue surveillance through EGDs and biopsies for life.....

I would certainly make sure I had a surgeon who has done many of these surgeries and make sure your surgeon does PH studies and manometry as part of pre-op testing..

One thing you have to understand about some of the web sites and support boards is that the people that mainly post there are the minority that continue having problems after surgery..Most of the ones that have a successful surgery don't hang around, they are out living their lives..

I hope this helps,
Tessa

[benderbabe]

Thanks Tessa.  I've been onto that site, and have watched a video of the cinch procedure.

It's too bad there's not longer-term info on the newer procedures. I'm not a fan of any kind of surgery unless absolutely necessary, and the less invasive the procedure, the lower the risk, as far as I'm concerned.

I'd be curious to know your feelings on the surgery, having had it...if you think it was worthwhile.  The stats on it seem to indicate that in many cases it's not worthwhile, as there is none to very little improvement.

The reasons for considering it are, as you said, if you can't deal with the lifestyle changes, or are looking at likely Barrett's esophagus or worse.

[tessa0825]

Hi, I wanted to tell you that I had fundoplication surgery  (the surgery that surgeon is referring to) last Sept...Im not going to go into alot of my experience, because most of them are done laproscopic. Mine was done open because I was having another surgery combined with it. I had a very damaged esophagus (from untreated GERD)...I have talked to alot of people who had lap fundoplication. There is a web site www.heartburn-help.com that has alot of forums and one of those are a nissen fundoplicatin forum..Alot of people talk about their experience with this surgery...There is also a forum explaining the other less invasive procedures (stretta, and endocinch).... Surgery seems to be a good option for people who don't want to be on medication forever and who have a hard time with the lifestyle changes...Tessa

[surgeon]

I've had several patients referred to me because of asthma and GERD, who have continued despite various medical measures. Fundoplication has been very beneficial. As was said above, laparoscopic fundoplication is a much less "invasive" procedure than the open method, and typically has very rapid recovery. I know there are some excellent laparoscopic surgeons in Australia -- George Fielding in Brisbane is world-famous (especially for bariatric -- obesity - surgery, but he's an excellent laparoscopist.) The other procedures mentioned are pretty new, with little or no long-term track record: I'd predict a significant failure rate over time.

[benderbabe]

Thanks Tessa.  He used to drink about 6 or 8 cups a day in his 20s, but now that he's twice that age he only drinks one or two cups in the A.M., which really isn't that bad.

His vice now really is that he loves chocolate and sweets, and shovels them in all day! :)  I finally got him off all those sweet, acidic drinks like coke and Gatorade...he drinks just a specially balanced bottled water here, which is at least good.

I don't think he's actually in that bad a state considering some of what I hear about this disease, but better to start improving his lifestyle now, slowly, rather than having to be shocked into it at some point when things get worse.

I know what you mean about fear being a good motivating factor. My dad was diagnosed with late-onset diabetes 2 years ago.  His mother went blind and then eventually died from this, over a 15 or 20 year period.

He didn't want to go through the same thing himself, so he said, "That's it, I'm changing my diet." The doctor told him once you had it you couldn't get rid of diabetes.  He said, "We'll see about that."

He has since lost about 50 or 60 pounds (he was always a big guy too). He looks and feels great, and is a lot more active.  He monitors his blood sugar, and is no longer considered diabetic....and he did it all with diet, motivated by fear!

[tessa0825]

I have been using zelnorm twice a day for many months now...It certainly works to help motility and I havent had any bad side effects from it...I hope you can get your husband to better understand the importance of diet with this illness...I was an absolute coffee-holic before I got sick..I have went from about 20 cups a day to 1 cup of decaf daily, sometimes I dont even drink that......If you get scared enough you can make all sorts of changes..Its a shame most of wait until we are at that point...Best of luck to you and your husband...Tessa

[TJV]

Zelnorm ( IBS drug)is called Zelmac in Australia i beleive as in most parts of the world.

[TJV]

Zelnorm ( IBS drug)is called Zelmac in Australia i beleive as in most parts of the world.

[benderbabe]

I think the drug Tessa refers to, Zelnorm, is probably what is called Motrilium here in Australia. I don't remember the generic name of the drug, but they often change the name between countries, so it's probably one and the same.

I'd love to hear from anyone out there who's tried it, as to what they think of it an any side effects (or lack thereof) they might be familiar with.

[benderbabe]

Thanks for your help Chicken Soup. I would love to hear some recommendations of good specialists downunder.  We live in Sydney...for those living here who will be familiar with the areas, we live on the lower north shore, and currently see a specialist at the North Shore hospital complex.

Yes, I agree with (and am alarmed by) pretty much everything you said.  That's why I'm starting to use a little "tough love" with the husband...he's such a big baby about changing his lifestyle, but personally I think I'd rather change my lifestyle and HAVE a life, so I'm working on him little by little.

He's a logical guy and he KNOWS that losing weight will help both his back and his reflux, but still he can't seem to get himself to do it. I want to get him a personal trainer and/or nutritionist, because it would make it a lot easier to just be told what to do to lose the weight.

The drug, Motrilium, I think it's called, is one of the drugs used to empty the stomach..it's fairly new, and supposedly has less side effects than the older drugs.  It has, in fact, just been cleared for use here late in 2003 I believe, and I don't think much before that in the US.

The thing I DON'T like about this drug is that it apparently works on the dopamine levels in the brain to control the motor functions of the digestive tract (the way I understand it anyway).  

Having watched my grandfather with Parkinsons on dopamine drugs, I wouldn't wish anything like that on my worst enemy.  They say the levels are so slight with this drug that it's "safe", but you've always got to wonder. My grandfather ended up halucinating and all kinds of stuff, very scary.

But one of the main reasons I think that surgery or some kind of "closing" procedure might be a better option for him is for that very reason...it's likely that it will do the job better than drugs alone (looks like at least 70% chance of this, and about a 80-90% chance of improving night asthma), and will lessen the chances of cancerous and/or pre-cancerous conditions of the esophagous.

So, I guess you could say that you hit the nail on the head, the concerns you noted are pretty much the same to mine.

Also, I don't believe they would have done and endoscopy without a biopsy to check the lining, but I honestly can't remember. This is one of the reasons (aside from symptoms getting worse) that he is going back to the specialist...to see how things are going in there, and make sure there are no changes for the worse, so to speak.

Anyway, thanks again for your help, and I would love names of some specialists here.  My mother-in-law is a biochemist and works at one of the main hospitals here too, so I'm sure she would have some names as well...she had also heard that the guy we're going to is well-regarded, so we'll see.

[tessa0825]

There is a newer drug that alot of Drs. are prescribing in place of reglan..Zelnorm is a motility drug that has very few side effects and is being prescribed for men as well as women..Initially it was thought to only help some women that had IBS-C...That is not the case any longer....
Tessa

[JackieG]

Hi Again Benderbabe:

Not to be an alarmist or create anxiety, but long term reflux (GERD) should be taken very seriously. Although not prevelant, esophageal cancer (in this case, adenocarcinoma is related to GERD. Squamus cell variety is related to long term tobacco and alcohol use) can result from long term reflux problems, and if your husband ever has to travel down that road, the statistics are very depressing. A combination of lifestyle changes, dietary changes and drug therapy can often keep GERD under control. If necessary, surgical intervention can also be of benefit. However, the dietary and lifestyle changes really have to be adhered to. I am sure you've heard of most of them from your research and/or the GI doc. Some foods relax the Lower Esophageal Sphincter (the "LES") and should be avoided, such as caffiene, peppermint, alcohol, and chocolate. Not eating within three hours of going to bed helps, and the bed elevation is a must in my view. It lets gravity become an ally in keeping the acid where it belongs. In addition to an acid inhibitor, you may want to consider Reglan, which helps the stomach empty more quickly. The less time food is in the stomach the less acid generation it stimulates. There was a drug called Propulsid that did the same thing, but it was pulled in the US a couple of years ago because of its rare but nasty side effects, including sudden cardiac death. I assume that your regulators have banned it as well, but if not, I would lean toward Reglan over Propulsid.

Although your husband won't like this answer, losing weight is important in trying to control GERD. If he follows a sensible diet intended to limit  acid production, weight lose may be the natural result. He should avoid all alcohol both because they contain "empty" calories and they weaken the LES.

Did the GI doc do any biopsies with the endoscopy to see if your husband has Barrett's Esophagus? Also, I wonder if the asthma is the result of mild aspiration at night? Aspiration (acid backing up into the esophagus and getting into the trachea) is not that unusual with a loose or non-functioning LES and I would ask the GI doc if it could cause asthma or perhaps cause asthma-like symptoms.

As you and your husband already know, controlling GERD is difficult, and the dietary and lifestyle changes require real conviction and discipline. I think you'll both find them worthwhile, and the downside risk of not controlling GERD can be pretty devastating. Unfortunately, I know from personal experience. I also have several Internet esophageal cancer friends who live in Australia. I realize its a huge continent, but they may have some ideas about well-regarded GI docs. What city are you in?

Don't mean to alarm you.
Best regards,
Chicken Soup

[benderbabe]

Hi guys.

Thanks for your comments.

Yes, I was astounded that this guy said that elevating the head would not help the GERD too.  It seems to be the number one recommendation to help GERD which is out there.

My husband wonders why I am doing so much research on the subject, but it's because I want to make sure that the recommendations this guy is giving correlate with most of the other info out there...if not, time to get a second opinion from a second specialist.

This particular guy is supposed to be one of the leading gastroenterologists in Australia, and I can't help but wonder if my husband is just remembering this conversation wrong, because he hates sleeping with an elevated head...it makes his back MUCH worse!  Unfortunately, the reflux and herniated disks are a lethal combination, as the relief from them requires nearly OPPOSITE treatment!

So far, the husband has only ever taken Omeprazole for the GERD, and I can't help but wonder, from what I've read, if some other combination of drugs will be more effective for him now that the night asthma has been identified.

I seem to remember that the sphincter muscle was basically not working (closing) at all, when he had the endoscopy, so maybe one of the newer motility drugs like motrilium would help him more, combined with an H2 blocker at night.

Thanks for the comments on asthma!  I will be heartbroken if the asthma is cauing the reflux, rather than the other way around, and we have to get rid of our feathered friend! (On the other hand, it would be a better deal for my husband if that simple act would cure the problem).

I'm still quite intrigued by Stretta and such procedures, as they sound like they have a similar success rate to the surgery without being as invasive.  For my husband, with needing to also treat his back, and with loving to eat, it might be a better option than drugs, which don't really "CURE" the problem at all.

[mao4]

I am 38 had never had asthma until 5 years ago.  We cut down our trees, bought a purifier, got new carpet,etc. etc. I could not figure out why I had never had asthma before and then it came on so severe.  I was using an inhaler daily.  Then 1 month ago I choked on a piece of steak and went to the ER they found out I had GERD.  My esophagus was 9mm, the avg is 20mm.  They did a simple 4 minute procedure using a "balloon" and widened my esophagus.  I have not used the inhaler 1 day since!!! It is wonderful.  I actually made the correlation myself after a little research.  I'm not a Dr. but I believe the asthma is related to the GERD.  Now I'm waiting to see if i have a hiatal hernia which could be causing the heart palpitations i have also had for years!!  I understand many people with GERD have hiatal hernias.  Go see a GI DR.    good luck

[JackieG]

Hi Benderbabe:

You need to get a new Specialist. The fact that your Specialist is telling you that elevating the head of the bed does not help GERD is truly astounding. It is part of the standard recommendation for lifestyle changes always recommended for treatment of GERD. Your Specialist should know this, and being so wrong on this account makes one wonder what other ill-informed information that Specialist is giving you!!!

I'll let "Surgeon" and Dr. Kevin comment on the Stretta procedure. However, laparosopic fundoplication is quite common now, and is a minimally invasive procedure. It was not available when I had my open nissen fundoplication in 1991, and laparoscopic surgery generally lowers risks associated with surgery, lowers the pain level, and hastens recovery from surgery.

I can't comment on the rest of your post, but PLEASE get a new Specialist.

Best regards,
Chicken Soup

[Kevin Pho, MD]

To answer your questions:
1) It is possible for the bird to be exacerbating the symptoms.  If the symptoms continue despite treatment, allergy testing can be considered.

2) Treatment would depend on what is causing the symptoms.  If the asthma is worsened by the GERD, then optimizing acid-reduction therapy can be considered.  If not, then a pulmonary evaluation for treatment optimization can be considered.

3) Weight loss would likely improve the symptoms of GERD.

4) Experimental approaches to the treatment of GERD involve placing sutures in the lower esophageal sphincter, applying radio-frequency energy to the lower esophageal sphincter, or injecting a chemical into the lower esophageal sphincter to strengthen it. These techniques are accomplished during an upper endoscopy (and thus do not require open surgery or laparoscopy) and can be done without the need for hospitalization. Very little is known regarding the short-term efficacy, long-term efficacy, or safety of these techniques.

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:
Charette et al.  Patient information: Gastroesophageal reflux disease.  UptoDate, 2004.