GERD excluded due to pH test?!

I was expecting to go into the doc yesterday afternoon to be told that surgery was the right course for me.

Instead the doc told me that I do not have any acid reflux.  This is the same doctor that completed an endoscopy on me earlier this year and told me and from his report:

"

Diagnoses identified:

Established Mild Erythematous (hypermic) gastritis

Established Mild Erosive duodenitis

Esophageal Stricture Benign appearing

Reflux esophagitis

Gastritis

Duodenitis

"

After the endoscopy he told me after the fact that my GERD was very severe.  He did dilate the stricture.

Yesterday, after reviewing the motility report that the nurse described as "incompetent LES, UES and weak smooth muscles" - he stated that motility seemed fine.  I never saw the pH report.  He told me that it was fine and that I do not have GERD.  He wanted me to switch back to high-dose Nexium twice a day - and then call him after two weeks only if things do not improve.  Thing is, he's had me on this dose before - and only thing that improved was a chronic cough.  Everything else either stayed the same or got worse!

First things first:  I'm meeting with my PCM today to get a referral to see a new GI doc.  I'm going to request one in the same hospital as an endocrinologist I've been working with.

What I am looking for are ideas of what may be going on with me.

My diagnosed conditions:

Hypogonadism - not sure yet if it is primary or secondary - am on HRT

Seasonal allergies - at the tail end of immunotherapy which has helped greatly

Anxiety disorder (docs are conferring on the appropriate diagnosis - GAD, OCD or bipolor or some combination... the OCD is definitely part of the equation)

Depression

Additional symptoms outside of typical GERD-type:

Frequent diarrhea - atleast one episode a day - sometimes as many as 7.  3 is very common. 

I catch EVERY stomach bug that comes around.

I on occassion have normal BMs...

It comes and goes in spells.

I have had stool analysis - all tested items were negative.

Some things I have come across:

Celiac

Chron's

IBD

Eosinophilic Esophagitis

The endocrinologist drew some extra blood tests to check some obscure causes of GERD symptoms.  He did this before we had test results and the GI Doc ruled-out GERD.

Any ideas, comments are appreciated!

I know that having a little patience is the best advise - but, reread the anxiety issues I have... I'm not good at being patient (or a patient, apparently).  SInce meeting with the GI Doc I have had four anxiety attacks.  So much to talk with the head-shrinkers about week after next!

 

I received a copy in the mail of the report. Each swallow isn't listed seperate and I don't see an average of DCI.

The Finding/Interpretation by the doc:

EGJ: Normal Relaxation
Mean IRP (1.2 mmHg) is less than 15mmHg.
Total 9 out of 10 wet swallows are peristaltic and conducted. One swallow was aperistaltic.
DCI<100 mmHg/s/cm in nine swallows. PFC is <9.0 cm/s in all conducted swallows. DL is >4.5 seconds in all conducted swallows.
Mean UES resting pressure is 20.7 mmHg, and relaxes completely during deglutitive process.

Conclusion
Ineffecive esophageal motility. No evidence of achalasia

Recommend:
Andi-reflux treatment and lifestyle modification
Follow up with referring physician.

Hi Ninjasm,

I would say the fact that 9 out of 10 swallows are peristaltic and conducted is good, the poor part that I see is your DCI is less than 100 mmHg, this means that the pushing part of your swallows are weak, so it sounds to me - though I'm no expert, but I also have motility problems - is that with a weak DCI of less than 500 then a nissen cannot usually be done. Now they could offer you a partial but that would be a risk, as if they put a wrap around your oesophagus, and your esophagus cannot push the food through you will get dysphagia. However, a lot of reflux can actually cause a reduction in peristaltic amplitude so a fundo can in some cases restore peristaltic function.


Your DeMeester score is within normal score, but you have a wide open LES and you are bound to be having free reflux.

I would ask a lot of questions and find an expert surgeon who has done hundreds of these, and make an appointment for a chat.

Does your report give you a distal amplitude?

I would suggest reading up a lot on partial fundoplications and other non invasive surgeries such as the endostim, there was a chap on here recently that had a DCI similar to yours and he got the Endostim done, though you have to pay privately for it. Might be worth going through the old posts and contacting him?

Sorry I couldn't be of more help, hopefully some of the more experienced will come along and help,

All the best,

Pink

There is nothing on my sheet that states distal amplitude.

The items that are given values on the swallows are (I'm posting averages)

LES risidual 1.2 (<15)
% failed Chicago Class 100
UES residual 4.7 (<12)
UES relax time to NADIR 65 (74-365)
UES relax duration 176 (480-1020)
UES recovery 111 (259-760)
Peak Phar. pressure @2.0 above mid UES 194.6
Phar upstroke @2.0 above mid UES 653.5
Contraction to peak @2.0 above mid UES 279
Contraction duration @same 427
Recovery Time @same 148
Phar start @same to UES start -288
Phar start @same to UES end -112
Phar start @same to UES Nadir -223

No.

Yes I can feel it. I also get massive spells of hiccups. But hiccup isn;t the right word. They are somewhere between a hiccup and a dry-heave - often they have a loud screeching sound as I violently inhale. Almost always followed by a belch.

I've been wondering if my extended period of time on Nexium 40mg twice a day could have had a longer-termed effect on the pH of my stomach acid. Maybe a higher pH of the juice was read by the monitor?

Would the low DCI be the metric that qualified my peristalsis to be failed?

Thing is - I used to have the dysphagia - until my LES was dilated. There really is no winning. Never tried wither of those.

I'm military - they really don't appreciate us going off to other nations for surgeries!

Ninjasm,

Just wondering how you have got on?

Pink

Andy and Pink - Thanks for checking in on me!

I just saw the new GI on Friday. Very glad that I fired the old one! This doc seems like a champ in comparison. He actually took the time to have a discussion with me instead of a lecture about Nexium's goodness at high-doses for life!

He agreed with you, Andy, on the pH test. He basically disregarded it and said that with the awfulness of my upper endoscopy, awful manometry and very obvious GERD symptoms, the test really wasn't needed in the first place.

A week from today I am getting an upper endo again to see if anything has changed in the last half year. He will also be performing a colonoscopy to investigate my lower digestive complaints. Still need to schedule a repeat of my manometry. He thinks surgery is best for me IF the manometry demonstrates appropriate esphagael strength.

As far as paying for procedures out of pocket - I would rather exhaust investigating all of the alternatives that my insurance covers first!

That 100% meant all swallows were FAILED.

Andy - funny you bring up the anxiety. I just came out of the "crazy closet" to my military and civilian chains of command. I was expecting frowny faces and a 'well, I guess we have to support you' attitude. Very far from the truth. There were frowny faces, but they were frowny concerned faces and there is a genuine attitude of 'whatever we can do to help' and comments like 'it takes a lot of bravery to face these issues and ask for help.' Took a TON of stress off of my shoulders. Still having panic attacks though!

Thanks diaba.

I wish I could see the full data (I am a data scientist for the Army)... 10 bucks says that while I spent very low time with at or below 4 - I spent a lot of time very close to 4. Wouldn't surprise me if out of force-of-habit I took a Nexium or two when I wasn't supposed to be!

Thanks Pink

I had my scopings yesterday. Everything on the back-end looked fine. Some biopsies were taken as well.

On the Endoscopy the doc observed that most of the damage that was demonstrated by everything from mouth to stomach had healed or greatly improved. He said that was due to diet changes, Nexium and sleeping upright. He thinks that my LES never closes at all - I have an appointment scheduled with him on the 10th (which will be after my motility study) to discuss surgical options.

His opinion is that my treatment should include surgery as long as the next motility study shows my esophagus is strong enough to support. My only other option is to continue taking massive doses of PPIs for the rest of my life (I'm 36) as well as diet changes (fine) and sleeping upright (that means I'm stuck on the couch... bad for marriage... and my back!).

Thanks -

I suppose these muscles are like any others - if you don't use them, they get weak! It takes no effort for materials to pass my wide-open LES - gravity can do it all. I wouldn't get very strong if I took the stairs down from work everyday and rode the elevator up!

I am off to get my next round of manometry in a few minutes.

The nurse called and left a message that biopsies from the scope returned and I still have esophagitis and gastritis. She emphasized twice to make sure I keep my appointment on the 9th.

I'm wondering if maybe there's a bile issue since I had my gallbladder out last winter...?