Friday, October 5, 2012

The Acid Reflux Saga

I've had problems with gastroesophageal reflux disease (GERD) since I was a teenager. By graduate school it had gotten so bad that I started taking the proton-pump inhibitor (PPI) Prilosec to control it. While it worked well for years, over the past year I began to realize that the daily pill that had controlled my reflux for eight years had started to lose its effectiveness. A little research found that this is relatively common for those who have taken a particular PPI for as long as I have.

I visited my doctor who prescribed a much stronger (and more expensive) PPI called Dexilant. Dexilant worked much of the time, but I'd have periods of one to two weeks where it just didn't seem to be effective. Concerned that the reflux could lead to serious problems like Barrett's esophagus, my doctor recommended that I visit the surgeon who removed my gallbladder earlier this year for further evaluation. The surgeon quickly scheduled me for a series of tests. These were meant to determine how bad my reflux was, what kind of damage it may have caused, and whether or not I was a candidate for a surgical solution. Given how long I've had this problem, it was believed that I might end up having surgery.

Who knew that the tests for evaluating chronic reflux could be so horrible?

The first test was the upper GI endoscopy. This involved putting an endoscope with a camera on the end down my throat to take pictures of the esophagus and the entry to the stomach. They gave me a sedative for this one (thank heavens). The sedative wasn't the same as a general anesthetic, but it might as well have been given how hard it knocked me out.

The finding of the endoscopy was that I had low level esophagitis and a mild hiatal hernia. Since I had taken PPIs for years, it was possible that my reflux was still pretty bad and that the acid hadn't been able to do too much damage yet, so it was on to the next test.

Esophageal Motility and pH Study
Before doing these tests, they made me stop taking any PPIs for a week. If I thought that my medicine was no longer effective before, I was shown how well it was still working during those seven days. It was definitely a long week. When I finally I went to the gastroenterologist's office, I was glad that I was finally going to get the test over with and be able to take Dexilant again.

Then they told me what they were going to do to me. Who knew that a test with such an innocuous name could be so unpleasant?

You've got to be kidding me
I could only laugh when the physician's assistant showed me the enormous probe (okay, its diameter was probably only 1/8", but it sure seemed big) that they were going to put up my nose, down my throat, and into my stomach. Then they were going to pull it out centimeter by centimeter while I swallowed syringes of Gatorade to assess the function of the muscles in my esophagus. The test was expected to take about 20 minutes but could take longer if I inadvertently swallowed at the wrong times.

The assistant made three attempts to insert the probe, but it kept jamming into the back of my throat and getting stuck. I gagged each time and eventually asked the assistant if anyone had ever thrown up on her. She said that no one ever had, but she kept a trash can nearby just in case. She finally called for the doctor to see if he could get the tube in. "I hear we've been torturing you," the doctor told me. "This is the worst test we do without putting you to sleep." The doctor was able to get the probe to make the U-turn in his first attempt and the assistant ran the rest of it in. This was as fun as it sounds.

The probe was so thick that the slightest movement caused gagging. Swallowing wasn't much easier. For the next 20 to 30 minutes the assistant squirted Gatorade into my mouth and had me swallow once each time. After 20 seconds of data collection, she would pull the probe out another centimeter and repeat the process. Normally I'm able to mentally distract myself from a situation (and yes, it is often by thinking of Warhammer 40K). However, I found it hard to think of anything other than the thick catheter that ran up my nose and down my throat and that was being pulled out ever so slowly.

The smile is definitely forced
Once that horrible test was done, I went on to part two. Part two wasn't much better. They were going to stick yet another piece of equipment up my nose and down my throat (this one with a 1/16" diameter). The sensor end of this probe would dangle just above my stomach while the other end would protrude out of my nose and would be attached to a small computer that I could hang from my shoulder. I had to wear this thing for 24 hours, while the computer continuously monitored the pH levels in my esophagus. I was supposed to push a button on the computer each time I had heartburn to indicate when I thought reflux episodes were the strongest.

Like the bigger probe, the pH sensor made it difficult to move my head without gagging. I was supposed to eat during the test period, which wasn't too much fun given that my esophagus had to push all food past the wire. Swallowing had the unfortunate effect of causing the wire to wiggle up and down, which made me gag slightly and irritated my nose. I spent almost the entire day on the Internet trying desperately not to move too much. Obviously sleeping was a challenge. The only positive was that my heartburn was at its worst that day, so at least I felt like I was giving them good data.

After 24 very long hours I went back to the gastroenterologist's office (the receptionists didn't even have to ask why I was there). Before taking the wire out, the assistant checked the computer's data card. As she accessed the card, I had a brief moment of panic when I imagined that the card had become corrupted and that I would have to wear the wire for another 24 hours. Thankfully the card was fine and I was able to go on to my next appointment without the hardware. I was told that the data would be processed and sent to my surgeon within a week.

Barium Swallow
The next thing I knew I was at the radiologist's office and was swallowing a chalky liquid with the consistency of paint. The physician's assistant apologized for the taste of the barium and how much I had to drink, but I assured her that it was a pleasure after having to wear that probe for a day.

I've gotten more radiation exposure from things
like this than I've ever gotten at work
The truth was that drinking the barium wasn't the hard part. The hard part was drinking the ground up Alka-Seltzer beforehand and trying not to belch. The stuff is intended to distend the stomach to allow the fluoroscope (a real-time X-ray machine) to get better images. When the process required me to lay on my stomach, it took a lot of effort to keep the gas down.

The fluoroscope was a pretty neat device that was operated with a joystick. Each time I swallowed a mouthful of barium, the radiologist would follow it down with the fluoroscope's emitter like he was playing an intense (and radiation-emitting) video game. The bed of the machine could rotate from a fully upright position to a prone position and we repeated the process with me standing up, laying on my side, laying on my stomach, etc. Eventually he had me do a variety of exercises meant to produce reflux, which he was able to record.

The barium swallow confirmed what the endoscopy had told us; i.e., that I had a small hiatal hernia. Like the pH data, the radiologist's findings were sent along to my surgeon.

And the Final Verdict Is...
Yesterday I went to the surgeon and he gave me his recommendation based on all the test results. I knew something was awry when he said "You're not giving me much to hang my hat on" and asked if I had stopped taking my reflux medication a week before the pH test. Yes, I said, my heartburn had been horrible the day I had the probe in. Lo and behold, the pH test showed that the acid levels in my esophagus were within normal limits. The esophagitis that the endoscopy had found was minor and simply indicated that I have a small amount of reflux that's relatively normal. The barium swallow confirmed that I have a small hiatal hernia, but those are extremely common and hernias that size don't generally cause a problem.

So why the heartburn? Well, every few months the surgeon sees a patient with an extremely sensitive esophagus. While the reflux they have is within acceptable levels, the pain and discomfort is considerable. Apparently I'm one of those lucky patients. "I'm a surgeon by trade, and I'd love to operate on you," he told me, "but I don't think it would help you." The nearest thing to a solution for this is PPIs since the surgery still permits a small amount of reflux to occur. Since my problem is a sensitive esophagus, I would still get heartburn after the surgery plus I would have all the unfortunate side effects that come with the procedure.

I'm not really sure how I feel about this. I'm glad that I don't need surgery and it's good that my reflux isn't bad enough to really damage my esophagus. On the other hand, I've just been told that my problem won't really go away and that I'm just going to have to be dependent on medicines that may or may not be effective for me anymore.

And it means that I had that %$#& probe up my nose for nothing.

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