GERD: Treatment Challenges and Patient Concerns - Gastroenterology and Hepatology

Q: GERD: Treatment Challenges and Patient Concerns

Hello： Gastroesophageal reflux disease (GERD) is a condition that is prone to recurrence, especially in individuals with a hiatal hernia. <br>In addition to pharmacological treatment, the following lifestyle and dietary recommendations are suggested： minimize smoking and alcohol

Issues in the treatment of gastroesophageal reflux disease (GERD)

To be honest, I have felt quite hopeless about this condition over the past six months.
I am only 24 years old and have been dealing with gastroesophageal reflux disease (GERD) since last year.
In August of last year, I underwent an endoscopy, which confirmed that the lower esophageal mucosa was red and inflamed, and my stomach and duodenum were also inflamed, but there was no Helicobacter pylori or ulcers.
The doctor prescribed NEXIUM 20 mg, which I took for three months and it improved by 90%.
Unfortunately, in November, after eating something spicy, my symptoms recurred.
My symptoms are somewhat atypical; I experience pain behind the sternum at the junction of the esophagus and stomach, but I do not have acid reflux reaching my throat or mouth.
Instead, I have a persistent dull pain in the epigastric area, which does not worsen when lying down to sleep.
At times, even drinking water can cause burping, and there is a burning sensation at the esophagogastric junction, although it is not very pronounced; the main symptom is pain.
When I am anxious or in a bad mood, the pain intensifies.
Additionally, drinking hot water or soup causes pain in the epigastric area, and hard foods also trigger pain.
In November, I consulted a doctor who increased my medication to NEXIUM 40 mg.
After a few days, I felt better, but one day I forgot to take my medication, and the next morning I woke up with pain in the epigastric area again, which was incredibly frustrating! The doctor kept referring to the results from my August endoscopy, stating that my esophagitis was mild.
They also conducted a CT scan of my abdomen and blood tests for my liver, gallbladder, and pancreas, all of which showed no issues.
I also had a colonoscopy in August, which was normal.
I have been very careful with my diet and have researched a lot about GERD, trying to improve my condition, but it keeps recurring.
I might be pain-free for a day, but then the pain returns after a couple of days, making it feel like I will never recover.
Because I am genuinely anxious about my condition, I went to a well-known private clinic in the north for another endoscopy, which claims to use the latest NBI staining and magnification techniques from Japan.
However, I felt that the consultation was not very thorough, possibly due to a high volume of patients that day.
The doctor asked only a few basic questions, and after the examination, provided a brief explanation before prescribing medication without giving me time to ask questions; the nurse just ushered me out, which was quite frustrating.
They prescribed self-pay medications similar to NEXIUM, such as PANTALOC 40 mg, along with some adjunctive medications to reduce gastric gas, which I understood since I had previously been prescribed similar medications.
The doctor hoped to review my reports and endoscopy images to address my concerns.
The report findings were: 1.
Larynx: No significant abnormalities.
2.
Esophagus: Gastroesophageal reflux disease, Type M.
3.
Stomach: a.
Superficial gastritis (erythema in the gastric fundus) b.
Moderate hiatal hernia.
4.
Duodenal bulb: No significant abnormalities; descending part: No significant abnormalities.
5.
Helicobacter pylori: Negative.

I have several questions I would like to ask the doctor in detail:
1.
Is my condition considered mild in the eyes of a gastroenterologist? If it is indeed mild, why do I feel discomfort and pain throughout the day?
2.
Is the best treatment for my condition PPI? Why was NEXIUM 20 mg effective at first, then ineffective after a recurrence, and then effective again at 40 mg for a while before becoming ineffective? Can PPIs lose their effectiveness, or should I regularly switch from one PPI to another? According to this endoscopy report, do I still need to continue PPI treatment? How long should I take PPIs? Is there a chance for complete recovery, or will I need to take medication for life?
3.
Is the inflammation in my esophagus currently mild? Is there a risk of it worsening? How far am I from developing Barrett's esophagus or esophageal cancer?
4.
Is the hiatal hernia congenital or acquired? If it is congenital, shouldn't I have experienced acid reflux and esophagitis as a child? Why is the inflammation in my esophagus only occurring now? Could various factors have led to dysfunction of the lower esophageal sphincter, causing the inflammation and pain?
5.
Besides surgery, are there any methods, such as medications or other treatments, to address the hiatal hernia?
6.
Based on these examination results, when should I have a follow-up endoscopy?

Chen Jiaju, 20~29 year old female. Ask Date: 2013/01/15

Dr. Chen Qifeng reply Gastroenterology and Hepatology

Hello: Gastroesophageal reflux disease (GERD) is a condition that is prone to recurrence, especially in individuals with a hiatal hernia.
In addition to pharmacological treatment, the following lifestyle and dietary recommendations are suggested: minimize smoking and alcohol consumption, limit tea and coffee intake, avoid spicy foods, reduce consumption of glutinous rice, and refrain from overly sweet or sour foods.
Soft drinks, such as cola and milk tea, should also be consumed sparingly.
It is advisable not to eat anything for three hours before bedtime, elevate the head while sleeping, avoid wearing tight clothing, and refrain from overeating during meals.
Furthermore, symptoms may not necessarily correlate with findings from endoscopic examinations, and currently, surgery is not highly recommended.
Wishing you good health, Dr.
Chi-Feng Chen, Taoyuan Hospital, Department of Health.

Reply Date: 2013/01/15

More Info

Understanding Gastroesophageal Reflux Disease (GERD) can be quite challenging, especially when symptoms persist despite treatment. Your experience reflects a common struggle among patients dealing with GERD, and it’s important to address your concerns comprehensively.

Firstly, GERD is characterized by the backward flow of stomach contents into the esophagus, leading to symptoms such as heartburn, chest pain, and discomfort. Your symptoms, including the pain at the junction of the esophagus and stomach, are indeed indicative of this condition. The fact that you experienced significant relief with Nexium (esomeprazole) initially suggests that you were responding well to proton pump inhibitors (PPIs), which reduce stomach acid production.

1. Severity of Your Condition: While your gastroenterologist may classify your esophagitis as mild, the subjective experience of pain can vary greatly among individuals. Some patients may have significant discomfort even with mild inflammation, while others may have severe inflammation with minimal symptoms. The key is that your symptoms are valid, and they warrant attention and management.

2. Treatment with PPIs: PPIs like Nexium and Pantoloc are indeed the mainstay of treatment for GERD. It’s not uncommon for patients to experience fluctuations in symptom control, where a medication that was effective becomes less so over time. This phenomenon can occur due to various factors, including changes in diet, stress levels, or even the progression of the disease. Some patients benefit from rotating between different PPIs or adjusting the dosage. It’s essential to have a discussion with your doctor about the duration of PPI therapy; many patients may require long-term treatment, but this should be monitored regularly to assess the need for ongoing therapy.

3. Risk of Complications: Your concern about the potential for Barrett’s esophagus or esophageal cancer is understandable. Barrett’s esophagus is a condition that can develop from chronic GERD, where the lining of the esophagus changes due to prolonged acid exposure. Regular monitoring through endoscopy is recommended for patients with chronic GERD, especially if symptoms persist. Your gastroenterologist can provide guidance on the appropriate intervals for follow-up endoscopies based on your specific risk factors and symptoms.

4. Hiatal Hernia: The presence of a hiatal hernia can be congenital or acquired. It’s possible that factors such as obesity, pregnancy, or increased abdominal pressure could have contributed to the development of your hernia over time. The hernia can exacerbate GERD symptoms by affecting the function of the lower esophageal sphincter (LES), which is responsible for preventing acid reflux.

5. Management of Hiatal Hernia: While surgery is an option for severe cases, many patients manage their symptoms effectively with lifestyle modifications and medications. These may include dietary changes, weight management, and avoiding triggers like spicy foods, caffeine, and alcohol. In some cases, endoscopic procedures may be considered, but these are less common than surgical interventions.

6. Follow-Up Care: The timing for repeat endoscopy can vary based on your symptoms and the findings from your previous exams. Generally, if your symptoms are well-controlled with medication, your doctor may recommend a follow-up in 1-2 years. However, if you experience significant changes in symptoms or new concerns arise, you should consult your physician sooner.

In conclusion, managing GERD can be a complex process that requires a tailored approach. It’s crucial to maintain open communication with your healthcare provider, express your concerns, and work collaboratively to find the most effective treatment plan. Your symptoms are real, and with the right management strategy, there is hope for improvement and a better quality of life.

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