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Doctor insists PPI is needed no matter what

Printed From: Barrett's Support Forum
Category: Barrett's Support Forum
Forum Name: Barrett's Oesophagus
Forum Discription: Your Questions about Barrett's Oesophagus
Printed Date: 01 Jun 2020 at 10:43am

Topic: Doctor insists PPI is needed no matter what
Posted By: mwoodj
Subject: Doctor insists PPI is needed no matter what
Date Posted: 29 Mar 2019 at 4:00pm
I am a long time reader here and I'm happy to now be a member. I was diagnosed with 3cm non-dysplastic BE 11 years ago at the age of 24. I have taken 40mg Nexium once daily since then and it has worked pretty well during that time. I have had my regular surveillance scopes every 2 or 3 years and the BE has never changed. A few years ago I changed to generic esomeprazole to save money. It worked the same as the name brand for me. Around the middle of last year I changed to 40mg generic omeprazole due to a change in the drug coverage from my insurance company. The medication worked alright but I did have more frequent episodes of breakthrough reflux requiring me to supplement with antacids a couple of times a month. In November I had a serious breakthrough event with residual lasting for days and I was unable to eat very much during that time. My GI scheduled an early scope to check on things and the BE was unchanged and the only other finding was gastritis as well as fundic polyps which were also present during my last scope. Those are caused by longterm use of PPI. I suffered more significant breakthrough events through November and December so right before Christmas I asked to be switched back to Nexium. My insurance would only cover the name brand and the copay was high but with the use of their copay assistance it was a wash. Switching back to Nexium helped a lot. I am continuing to have some issues though including a burning skin rash that started shortly after switching back to Nexium, epigastric pain that does not seem to be associated with meals and feels different from heartburn as I'm familiar with it, and chronic elevated pancreatic enzymes (amylase 2x upper limit) since at least the beginning of the year. Obviously I am paying a lot of attention to those issues and have had a lot of imaging done so far this year which has found nothing so far.

While I'm dealing with the above I have consulted with a good thoracic surgeon about getting a Nissen fundoplication. He was not pushy and he told me there are reasons to do it and reasons not to. He said that, given my history and current condition, he believes I would be happy with the procedure. I have discussed the procedure with my GI and he is not in favor of any surgery for BE patients. He believes that lifelong PPI therapy is the correct solution. Further he says that he would not approve of PPI cessation if I did go through with the surgery. I am confounded by this position. I have tried to keep up with BE studies over the years and I am aware of data showing that PPI may be a chemopreventive in those with BE. I have also seen studies that showed no difference in progression between those that take PPI and those that get NF. He contends that patients with NF may not feel that they are refluxing and that he has had NDBE patients who got NF and subsequently had cancer at their three year followup (which I find dubious given the rarity of such a progression). I have not been with this doctor for long. My longtime GI retired and I started seeing this doctor last year. I relied on the advice of my GI before but I am having a hard time feeling the same way about the new doctor. I just don't think that his position is supported by the current data. I agree that the data supports the idea that treating acid reflux likely (though not definitely) decreases the chance of progression. I don't see that it shows that PPI is better than NF in that regard. In addition the PPI does not relieve regurgitation which I experience frequently. Any thoughts?

Posted By: chrisrob
Date Posted: 01 Apr 2019 at 10:22am
Hi and welcome.

Most GI docs are medics rather than surgeons and are likely to focus on medication. However, - PPIs reduce acid not reflux .

I was on 80mg omeprazole for years prior to - surgery .
It was the best thing I ever did. All reflux symptoms stopped and I immediately came off medication.
(Last year I restarted omeprazole at a low dose as I had a small amount of oesophagitis.) - This study concluded, "LNF achieves better improvement than PPIs for LPR with type I hiatal hernia."

And - this study concluded, "Both antireflux surgery and medication may be associated with decreased risk of esophageal adenocarcinoma in patients with GERD, decreasing to a similar level as that in the background population over time."

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Posted By: mwoodj
Date Posted: 01 Apr 2019 at 6:05pm
Thank you for that. I am going to get a second opinion from a highly rated GI in my area. I have time to do further investigation because I do not plan to have the surgery done until the fall. If I do get it done I definitely intend to try to stop taking the PPI. I am not sure if my current symptoms are still attributable to PPI failure or if they are related to the elevated pancreatic enzymes. The serum amylase level is hovering around 75% to 100% above upper limit of normal. That is not high enough to be pancreatitis. Both a CT scan and MRCP showed no abnormalities in the pancreas or ducts and I do not have a gallbladder. The GI thinks sphincter of oddi dysfunction is a possibility. I am going to have an EUS and ERCP with manometry. I feel that should that yield no results I want to ask for another endoscopy to see if there are signs of continuing reflux and to have a Bravo pH monitor put in. Does that sound like an unreasonable suggestion? I think my GI may point out that he did an endoscopy and took biopsies in November. I was not terribly satisfied with that endoscopy as he indicated that he was having difficulty taking pictures and the report did not include any pictures of the BE. This was the first time this doctor has done my endoscopy and he stated that he believes my BE has regressed (which is something no previous doctor has ever said after I had an endoscopy.) I am skeptical of the idea that BE regresses on its own with or without PPI therapy.

Posted By: chrisrob
Date Posted: 07 Apr 2019 at 11:27am
Barrett's is a permanent addition of "armour plating" cells to the oesophagus to protect the body from erosion of acid. It does not regress but can be misdiagnosed (eg if biopsies taken below the z-line) or new mucosal layers may form over it.
PPIs will reduce acid and probably reduce risks of Barrett's progressing towards cancer.

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Posted By: TEEL
Date Posted: 10 Jun 2019 at 11:25pm
I have been dealing with reflux for several years now and was told I had stage 1 of Barrett's Oesophagus and was put on 60mg of dexilant. One year later tested negative but still needed meds for reflux and reading dexilant is not good long term. So 4 days I had the full wrap of the Nissan fundoplication and they found I also had a hernia and repaired it. So far I feel much better from the reflux side but just started the soft diet part now. So far I am happy and glad to be off the meds.

Posted By: chrisrob
Date Posted: 16 Jun 2019 at 12:35pm
Join the club.
I've had reflux all my 70 years and been actively studying it for the last 15. I know I've had my Barrett's at least 25 years.
Most, if not all, of us with Barrett's have, or had, a hiatus hernia which is what permitted the reflux of acid and bile contributory to the Barrett's formation, to develop. (See - this simple guide .)
But there are no stages for Barrett's. - Oesophagitis that can lead to Barrett's can be staged using Savary Miller scale (1-5) or Los Angeles (A-D). Barrett's is Gastric or Intestial metaplasia (though Gastric metaplasia is not regarded as Barrett's in US).
If Barrett's is going to progress to cancer, it will first go through dysplasia, classified as low or high grade. If dysplasia is seen, Barrett's may be - ablated .

But don't believe all you hear about the dangers of PPI medication (Dexilant etc). Read the facts here: - Controversy over long term medication.
Dexilant is also over priced and over-hyped. It is nt available on NHS in UK as cheaper alternatives have been shown to be just as effective when taken in comparative dose. (See - Proton Pump Inhibitors .)

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