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Weak LES - Stay on PPI Indefinitely

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Posted 12/22/2014 9:22 AM (GMT 0)
Hi all,

I have a few questions but here's a brief background of my journey with GERD the past one year.

My reflux symptoms started November last year and varied over the next few months: dry mouth, sore throat, cough, burning tongue, and lump in throat sensation. I experienced heartburn only a couple of times. Endoscopy in January showed irregular Z-line indicative of mild GERD. 40mg Nexium and 20mg Nortriptyline provided me with a great deal of relief. My symptoms are now limited to paresthesia (tingling) in the mouth (Nortriptyline brought it down from severe to mild), regurgitation of liquids to the throat, and occasional lump in throat sensation. I tried doing the 24-hour pH impedance test in August but failed it. My gag reflex was too sensitive and my nose and throat were not numbed. I really wanted to find the cause of my GERD. I'm 22, fit, don't drink or smoke, and have a good diet, so I thought that I might have hiatus hernia. I went for a barium swallow test this past weekend. X-ray showed no hiatus hernia, but the radiologist said that my LES appears relaxed.

My GI doctor said that some patients do get off PPI eventually when they find that their symptoms have disappeared. But what are the odds of that happening? Because it seems like most GERD sufferers stay on PPI lifelong. Anyone here managed to get off PPI without any other treatments? I'm thinking that patients who managed to get off PPI probably don't have a weak LES. If you have a weak LES, then you're always going to reflux, and the question is how acidic are the reflux episodes. Hopefully 40mg of Nexium is keeping the acidity in control, because I haven't been able to bring myself to do the pH impedance test or Bravo capsule study.

Was I born with a weak LES or did my LES undergo an anatomical change and became weak? I don't fit into the demographics of GERD sufferers. I was 21 when it started, not overweight, don't drink, and have a relatively good, healthy diet. How did I have GERD all of a sudden?

Any input will be greatly appreciated.
Posted 12/22/2014 12:43 PM (GMT 0)
The LES relaxes in everyone that has GERD/LPR. This usually happens when eating things like spicy foods, mint. fried food or drinking caffeine and things with citric acid. These food and drink items can cause the LES to relax.

However, if this happens when you just eat a cracker or some corn, then there is something more going on. Then I would first get tested for food sensitivites or delayed gastric emptying. Both of them can cause GERD/LPR.

Your allegerist can test you for food sensitivites. There is also an out-patient test for delayed gastric emptying you can have done at your local hospital.
Posted 12/22/2014 8:51 PM (GMT 0)
Get some d-limonine and wean yourself off ppi's for good. I'm not kidding! See the other post on this.
Posted 12/22/2014 8:56 PM (GMT 0)
I was on PPIs for many years, managed just fine as long as I wasn't eating one of my food triggers. I only had the surgery because of an accident that pushed my stomach into my chest.

Pharmaceutical companies say PPIs should only be used for a short time, but that's simply not possible for a lot of us. I had a bad LES, so I just kept my stomach non-acid and had no esophageal problems.

I wouldn't have fussed at all, but I didn't know the reason for my refluxing up stomach liquids was due to specific food intolerances. When my allergist got me to keep a food journal, and I stopped eating those particular foods, I stopped having those reflux events. Stomach liquid could still run into my esophagus, but stopping eating long enough before bed that my stomach wasn't full and using a couple of pillows took care of the nighttime choking.
Posted 12/22/2014 11:38 PM (GMT 0)
I can feel water backing up to my throat at 3 or 4PM in the afternoon when my stomach isn't full. My GI doctor said that it could be due to esophageal hypersensitivity.

Here's a good site on esophageal hypersensitivity: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950665/

I'm finding that tomato ketchup and potato chips worsen the paresthesia in my mouth.

Have any of you ever been told by your GI doctor that your symptoms are functional? These functional symptoms classified as non-erosive GERD. But I'm thinking that the PPI that makes it non-erosive, and the prior acid reflux somehow caused my esophagus to be hypersensitive. I just don't see how any of us with a weak LES can get off PPI for good. If you have a weak LES, then you're always going to reflux, and the best "solution" is to minimize the acidity of the reflux.
Posted 12/23/2014 4:56 AM (GMT 0)
Some people do not have problems with PPIs, but for pther people they can lower their stomach acid too long. If this were to happen, it can lead to delayed gastric emptying. When you have delayed gastric emptying both food and what little acid remains in the stomach keeps being pushed up into the esophagus. Since the lining of your throat is completely different than the lining of the esophagus, it does not take much acid to burn the throat.
Posted 12/23/2014 5:38 AM (GMT 0)
Hi Space115,

LES is mediated by the vagus nerve (pneumogastric Nerve). Drugs that modulate vagal function are useful. Gabapentin. Baclofen.

See

http://www.nytimes.com/health/guides/symptoms/heartburn/medications.html

Stress disrupts autonomic nervous function during sympathetic activation.

Talk to your doctor about above meds. I've been on gabapentin since July for LPR and GERD and it's been helpful. Just recently off pantoprazole 40 mg on doctor's advice.
Posted 12/23/2014 11:37 PM (GMT 0)
There is no medical or homoepathic cure for a weak LES. Were you a "spitter" as a baby? My mom could follow the trail of milk to find where I'd crawled. I suspect I was born with a not terrific LES. No way to tell now.

A lot of people, including doctors, think only the GERD foods, caffeine, spicy foods, etc. trigger reflux. By reflux I mean the stomach actively heaving its contents into your esophagus. When I had a barium swallow this action was visible on the screen several minutes after swallowing the stuff. I know now that I might not have had this reaction if the stuff was "clean," clear of certain additives, which I now can predict will cause this reaction. I also had the stuff flow up the esophagus when I was tipped into a lying down position, but that just showed the weak LES.

My esophagus and stomach react to certain chemicals in a well-known group of foods. This triggers my vagus nerve to cause reactions elsewhere, in my individual case, my heart. I get tachycardia after the stomach reacts. It has nothing to do with my weak LES. That was weak without being triggered. The heart reaction is called "cardioesophageal reflex," and you can google several scientific papers.

Ketchup is one of my triggers. It's the vinegar in it - not because of acid, because I'm fine with rice vinegar, but because it has sulfite in it. I got horribly sick at Thanksgiving from a sliver of pumpkin pie - the sulfite in the ginger.

It's free and easy to keep of food journal and find out if you have specific food triggers. It won't cure a weak LES, but it can stop misery if you find you need to avoid certain foods. Just put a small notebook on the kitchen counter and write down the time and everything you eat or drink for a month or two. Also write down any reactions.
Posted 12/24/2014 8:46 AM (GMT 0)
I'll talk with my doctor about Gabapentin and Baclofen.

Is it possible for the acid reflux to cause esophageal hypersensitivity, which in turn causes food intolerances? I find that ketchup and potato chips trigger the paresthesia in my mouth, but it's difficult to find the exact ingredient.
Posted 12/25/2014 10:11 PM (GMT 0)
not always a weak LES, abdominal pressure on it is problematic, chiropracter friend says almost all reflux caused by 1 of several hernia types
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