Louise from Houston asked us this interesting question: When pH, motility and gastric emptying tests come back negative, yet there is still heartburn and only partial response to a PPI, what does one do? especially if one’s eGFR is in the 40’s. Do you save the esophagus (in the hope that NERD won’t become GERD) or do you stop the heartburn pills to protect kidney function?
Fundoplication or LINX™? Horror stories abound on the internet!
Dear Louise,
Thank you for your interesting question. You touch upon a number of acid reflux related issues and controversies. I will try my best to clarify my answer for you. First, acid reflux diagnosis is the very first important step in acid reflux treatment. At Houston Heartburn and reflux Center, we utilize a number of diagnostic modalities to help diagnose and stage acid reflux. The diagnosis of acid reflux may not be straightforward all the time. This is where experience, training and expertise are helpful to differentiate GERD from NERD or heartburn from functional heartburn… If a solid acid reflux diagnosis is not made, heartburn patient treatment is incomplete, patient satisfaction is low and therapeutic outcomes are poor. You had a number of studies performed. An experienced acid reflux specialist will put all these study results together and meticulously go over your symptoms and history to come up with a conclusion.
Heartburn pills like proton pump inhibitors are associated with renal insufficiency when used over prolonged periods of time. I have a number of patients, at Houston Heartburn and Reflux Center, with renal problems secondary to years of PPI intake. Therefore, I am very cautious prescribing PPIs especially in the setting of renal insufficiency. I always to patients that if PPIs are helping you, Nissen fundoplication and hiatal hernia repair will help you more. Nissen fundoplication outcomes far surpass any other acid reflux treatment modality like LINX™. Properly performed hiatal hernia repair and Nissen fundoplication are safe, effective and durable. Our safety and efficacy record at Houston heartburn and Reflux Center is the ultimate proof.
Non erosive reflux esophagitis, NERD, represents less than 5% of all patients I evaluate at Houston Heartburn and Reflux Center. NERD patients have typical GERD symptoms but normal upper endoscopy. Distal esophageal mucosa shows no inflammation or erosions. NERD patients with a positive ambulatory pH or impedance study are offered Nissen fundoplication and hiatal hernia repair especially when they show partial response to heartburn pills. NERD patients with negative ambulatory pH or impedance testing and no response to heartburn pills are not likely to benefit from Nissen fundoplication and hiatal hernia repair. These patients are advised to stop proton pump inhibitor intake to avoid unnecessary side effects like renal failure. Esophageal neuromodulators like tricyclic anti-depressants and selective serotonin reuptake inhibitors are offered. Studies are needed in this field to determine the most effective drug regimen. Anti-reflux surgery, however, for NERD patients with negative ambulatory pH or impedance testing is not likely to help.