GERD, acid reflux, heartburn and hiatus hernia

I have cycled through several kinds of PPI. Some of them didn’t help at all. one seemed to make matters worse. Others helped for several years.

 

I started with heartburn & refux when i was 11. Nobody believed me at home - they just thought i was saying i had it because i heard my parents complaining of it. "You're too young for heartburn". But i remember the intrusive pain while at school, standing in the dinner queue & all my friends saying i was weird. But it hurt, and i had it on & off svereal days a week, my whole life. all different times of day, All kinds of different eating/food choices/regimes, goodness i tried them all etc over the years - made no difference. It was just awful, so painful and all the OTC medicines did absolutely nothing. I once ate a whole packet of rennies over about an hour & it made no difference.

My parents both had HH & my father was often to be found jumping hard down to try & make it descend. It never worked. Those exercises never worked for me either, nor did sitting up/raising the bed, it was the same standing up as lying down. But to be fair i never sought medical help i thought itwas just a thing you had to live with.

And then in 2002 I happened to mention it to a new GP i was seeing for something else. He referred me for endoscopy & H- Pylori test which was negative & endo looked fine. He put me on lanzoprazole 30mg. God bless him!

Within 3 days it was like a miracle. A miracle. In almost continuous pain since age 11 & it then just disappeared.

I tried to lower the dose but it came back so stayed at the higher.

So i been on them 20yrs this year. I became anaemic in 2011 & asked GP if it might be the PPI, he said 'oh no that wont affect anything'...... !!! But then 4yrs ago they started with a practice pharmacist doing the med reviews & she was concerned so i tried gradually, lowering dose, & i now on 15mg most days. Sometimes it isnt quite enough, so i take a 2nd dose for a couple of days & then it receeds again.

It concerns me greatly having been on them for so long, but i cant go back to that constant pain on top of everything else, i just cant.
But the absorption issues do worry me. So i've been very interested to read this thread and esp Jonathan's comments about the NICE advice, and the NICE GL itself i will review.

 

Just to add another N =1 in case it's helpful.

Age and health status ensured I got the full x ray, barium meal & back of the nose camera investigations (symptoms included persistent cough). Diagnosis was "some reduced esophagus motility" and "a small HH".

Advice from the Gastro-pods was on diet: No coffee, no chocolate (cruel b******s), no tomatoes, no citrus. Given my already reduced diet I decided to go cold turkey on the first two, cut out the third but keep the clementines. Did help. I also found that cold drinks were an issue.

PPIs were prescribed by GP and only subsequently was concern about long term use raised based around fracture risk:Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540255/

My decision is that as the PPIs work, that they took time to get used to*, and that I've enough other sources of discomfort to contend with I'm sticking to a daily pill and accepting a of risk crumbly bones. Should be said that I'm not exactly delicately built and not bed/sofa bound so I may not be at the higher risk end.

*Worsened IBS symptoms for about 3 weeks, but thereafter seemed to actually help with IBS, or maybe just coincidence.

 

What helped me with GERD and reflux was D-Limonene.

 

HH? Hiatus hernia?

 

Yes.

 

Laparoscopic Nissen Fundoplication is not without risk, though it seems pretty safe. In addition to the usual risk of complications of surgery, the operation is not always wholly successful and reflux can persist, or the tightening can be too great and remove the ability to vomit or belch, that latter leading to in increase in bowel gas. https://www.nhs.uk/conditions/hiatus-hernia/

Given the current state of backlog in the NHS I'd guess this kind of operation will be low priority for several years to come. Advice I was given 5+years ago was that LNF was only available for 'large' hiatial hernia - I can't recall what the large/small definitions were. This article seems to cover the basics of decision making over surgery or not: Which hiatal hernia’s need to be fixed? Large, small or none?

https://ales.amegroups.com/article/view/5885/html

 

As people age they produce less and less stomach acid. And yet who are the people most likely to be on acid-blocking or acid-reduction medications like PPIs? The elderly. And people who take PPIs are told they are necessary to reduce levels of stomach acid. The lack of logic is glaring but is rarely discussed or brought to people's attention. PPIs can be helpful for a short time in people who have ulcers, and also in people taking NSAIDs (Nonsteroidal anti-inflammatory drugs)

The problem of having too little or absent stomach acid (hypochlorhydria / achlorhydria) is a common one that occurs in many different conditions. See the following link :

Title : Achlorhydria
Link : https://www.ncbi.nlm.nih.gov/books/NBK507793/

There are valves at the top and bottom of the stomach to allow food in and to allow partially digested food out into the intestines for further digestion.

The question people need to ask themselves is what makes those valves open and close? And what makes them open and close at the right or wrong time? Reducing stomach acid is just a way of suppressing a symptom, it actually makes the underlying problem worse.

...

I learned about the opening and closing of the stomach valves from this series of articles :

https://chriskresser.com/what-everybody-ought-to-know-but-doesnt-about-heartburn-gerd/

The above link is to the first of 6 articles, but it might be easier to just download the free e-book offered on the same link.

Once I understood about the opening and closing of the top and bottom valves of the stomach the whole subject made a lot more sense.

 

I've always found the low stomach acid argument compelling. In fact back in the day when i was trying dietary modifications to try to fix it i tried Supplementation with hydrochloric acid. It didnt help. I dont think it made it a great deal worse or anything it just made no difference.

I also tried low/no carb regimes, these also made no difference to my GERD.

And if it's increased pressure as the cause, i am of healthy weight certainly not obese & the heartburn has always, particularly as a child, been worse on an empty stomach than after eating.

I do belch an awful lot & very powerfully since i been on the PPIs.

But even, lets say he's right & its SIBO + increased pressure, what the hell can one do about it? I mean the chances of getting a test & treatment for SIBO on NHS are pretty much zero for those of us with 'somatisation disorder' somewhere in our notes.

It makes me despair

 

Do you mean you took Betaine HCL or Betaine HCL with Pepsin in capsule form, or something else? There are various rules to be followed to get the right dose and to make sure it is taken under the right circumstances. When taken under the wrong circumstances it can make problems worse.

How to Supplement with Betaine HCL for Low Stomach Acid - Healthy Gut Company

4 Common Betaine HCl Mistakes - Healthy Gut Company

...

There are some people who have been on acid-lowering products for so long that apparently their ability to produce gastric acid is permanently impaired. So if their doctor takes their PPIs away from them they will not be well and will just go back to having the same problems as before they were treated with PPIs. Having a hiatus hernia will also require permanent help with reducing stomach acid as far as I know because the valve at the top of the stomach won't close properly. But how many people are checked to see if they have a hiatus hernia before being put on PPIs?

...

I first developed indigestion and heartburn in my teens which I was told to treat with standard antacids. I developed a duodenal ulcer in my late 20s which was treated with either Ranitidine or with PPIs, I can't remember which one exactly. Then I was cut adrift to just deal with it myself. I was then told in my 40s, following an endoscopy, that I had gastritis and I took Ranitidine for that until it was withdrawn, but I had to plead for the Ranitidine to be prescribed when it was available. Then I was cut adrift again until I actually pleaded to be prescribed PPIs. They may not be a good choice but after decades of problems I don't have any other options. I've tried giving up PPIs/Ranitidine/antacids and taking extra acid in the form of Betaine HCL, diluted apple cider vinegar or diluted lemon juice. They help for a couple of days then I'm back to square one again.

 

Effects of aging and gastritis on gastric acid and pepsin secretion in humans: a prospective study

Abstract
Background & aims: Recent studies suggesting that gastric secretion does not decrease with aging included few elderly individuals and measured only acid secretion. The aims of this study were to measure gastric acid and pepsin output in 206 health Americans (age range, 18-98 years) and to compare secretion rates with gastric histology.

Methods: Immediately after basal and pentagastrin-stimulated acid and pepsin outputs were measured, oxyntic biopsy samples were obtained.

Results: Gastric acid and pepsin output rates were similar in young (age range, 18-34 years) and middle-aged (age range, 35-64 years) groups. Stimulated acid output was reduced approximately 30% in the elderly (age range, 65-98 years). However, after adjustment for histology, Helicobacter pylori infection, and other variables, age had no independent effect on acid output. The decline in acid secretion in the elderly was primarily related to a higher prevalence of chronic atrophic gastritis and a lower prevalence of smoking. Pepsin output was reduced by approximately 40% in the elderly. After adjustment for other variables, age remained a robust predictor of reduced pepsin output.

Conclusion: Although advancing age has no independent effect on gastric acid secretion, it is associated with reduced pepsin output independent of atrophic gastritis, H. pylori infection, and smoking.

full article pdf: https://www.gastrojournal.org/action/showPdf?pii=S0016-5085(96)00158-8

"Decrements in gastric acid output began in the eighth decade, reaching a significant nadir in the ninth decade."

 

I cant remember. I think it had pepsin in as that rings a strong bell.

I did so many things read so many books, took advice from a nutrirional therapist, i cant remember the details of most of it, but i do remember follwoing a detailed set of instructions, i didnt just go to the shop & get a supplement i was follwoing instructions from somewhere/someone.

The trying of different things just went on for many years trying to cure both my heartburn and my IBS, which was a great deal worse back then than it is nwo. And nothing made the slightest bit of difference. I even tried to do a diary with my emotional state/life events to see if there was a pattern.

But there just was no pattern, no difference made by anything until PPIs came along.

I'm sorry you had such an awful experience too @Arnie Pye

 

When I officially became ill with ME, I had many distressing symptoms including intense heartburns. These heartburns have become chronic and therefore intolerable. Being already thin, it prevented me from eating and therefore I lost weight. Antacids sold over the counter in pharmacies didn't work, so my doctor prescribed me Nexium (Ezomeprazole), which luckily helped. But, like everyone else, I wanted to avoid taking this drug indefinitely and also to find out what was causing this problem. The waiting lists to see a specialist doctor here being very long, I had to "manage" myself. What follows is obviously only N=1, of which I don't even remember the "hypothesis" that motivated this test at the start : I take 1/2 cup of yogurt in the evening, every day. This fixed my problem. Why?, no idea or supporting evidence, and it is not without some embarrassment that I say this. However, if I stop, my heartburns starts again within 24-48 hrs.

A year and a half later, I had a gastroscopy (dx= gastroparesis, however this happens periodically, a few times a year. I suspect it might be related to my POTS... or not !).

 

My brain is struggling to take that sentence in. Is it saying that people who smoke have more stomach acid than those who don't smoke? That amazes me. It's suggesting that smoking might be good for something in certain people. :O

I was told by my GP over 20 years ago that my gut problems wouldn't go away until I stopped smoking. But if my problems were due to low stomach acid/pepsin production then there is a contradiction.

I now believe that my gut problems were mostly caused by being hypothyroid and untreated. I'd had symptoms since I was pre-school age. Low stomach acid production is often associated with hypothyroidism.

 

I'm a big milk drinker and can get through 6 liters, possibly 7 on my own a week. I've only had one very bad bout of acid reflux/stomach and that was at the time of my very severe ME onset.

The last 5 years or so I have been having a tiny bit of baking soda (less than a quarter tsp) in just under a quarter cup of milk and spoon it into my mouth. I don't even need to drink it all and I find that settles my stomach down very well when I get the ME/PEM stomach. I don't think this works for everyone though.

Milk is one thing I couldn't bear to live without.

 

that’s so interesting, I have to do the exact same thing! I’ve had severe upper stomach / acid reflux type pains since I was very young, and they never left. I get the pain if I haven’t eaten for a long time, but also if I over-eat too. Only thing that helps is famotidine / omeprazole, and yoghurt! I eat yoghurt when the pain comes on (as long as I’m not too full), and at night-time. It helps a lot..But I only discovered the yoghurt thing recently. It’s the remedy they use back in my mum’s home country too whenever people are very poorly with bad stomachs or struggle to eat proper food - curd/yoghurt (sometimes mixed with white rice to bulk it up).

yoghurt can be very soothing to the stomach, I find milk to be similarly soothing!

It’s horrible having these pains, especially when they get very severe. when young I spent many nights and hours in A&E due to the severity of the pain, only to be told to take gaviscon each time! But the last gastroenterologist I saw told me to continue taking the meds (omeprazole etc) if they help me. I don’t mind taking them, the important thing is that I have less pain and they allow me to function a bit more normally.

 

The smoking link is not related to stomach acid per se but to the impact smoking has on the esophagus and the lower esophageal sphincter. There's of research on the role of collagen - the idea being that smoking causes changes in collagen which reduces the effectiveness of the sphincter so it doesn't remain closed when it should https://link.springer.com/article/10.1007/s00464-016-4858-1

 

Do you actually have 'somatisation disorder' in your notes, JemPD? Or just 'ME/CFS'? I managed to get a SIBO test (positive) and antibiotics on the NHS some years ago with no problem.