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I have had symptoms of silent reflux for 5 months now and finally did a 24-hour esophageal pH monitor that confirmed I have reflux.

I'm in my 30s, I am 40 lbs overweight (which I know is bad, but I'm not "can't-get-off-the-couch" overweight) and I am not responding to any PPIs (my GI has tried me on omeprazole, nexium and dexilant).

Prior to doing the pH monitor, I had an endoscopy that revealed:

  • 3 nodules in my stomach that were biopsied and came back benign
  • No hiatal hernia

I also had "manometry" done that showed some slight abnormalities with my swallowing, where the lower esophageal sphincter (LES) wasn't relaxing properly as the "bolus" (the thing being swallowed) passed through my esophagus.

My diet isn't perfect but is orders of magnitude better than it was 5 months ago, and I've lost 25 lbs so far (so yes, I used to be ~65lbs overweight). Very little chocolate, caffeine and alchohol. I don't smoke.

I finally had a sitdown with my GI where I asked her if she had any idea what is causing my reflux since I don't have hernia, I've lost weight, my diet is under control and, most importantly I'm not responding to the PPIs.

She simply said she didn't know. I asked her if there were any surgical options available to me and she said that I wouldn't qualify for surgery because I would need to show a response to the PPIs first.


Finally, my question

I feel like I'm in No Man's Land. I have confirmed reflux, but am not responding to any of the things that normally treat it. Are there any other known causes of GERD that may have been overlooked here?

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    Are you asking about causes or about treatment? It seems that you assume that your problem should disappear once whatever caused it disappears, but this is not really necessary. It can happen, or the problem, once triggered, can persist. – rumtscho Nov 5 '15 at 18:59
  • Hi @rumtscho (+1) - I guess I'm not really sure what you're asking. But I am looking for the cause here. Once we know the cause, the treatment (or lack thereof) should be obvious. In my case, I'm not responding to any of the normal things that GERD patients respond to. For instance, some people respond by losing weight and eating a better diet. I've done both of these and still reflux daily. Most people respond to PPIs, I don't. So I'm wondering if there are other causes for a dysfunctional LES (neuroligcal? MS? etc.) that wouldn't be treated by diet and PPIs. – smeeb Nov 7 '15 at 0:19
  • Hi there @smeeb, we cannot diagnose you here. The wording of your questions lends itself towards that direction. If you reworded it into a more general case, say "What are possible causes for ____ given these current conditions, X, Y and Z?" we might be able to answer that, but in the the given state, I believe it's likely to be closed. – Dave Liu Dec 2 '15 at 22:15
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Only your healthcare provider can help diagnose and treat YOUR situation, so keep working with them on this.

But what I can do is help reflect your own statements back to you.

Regarding the recommendations that your doctor gave you:

(1) You say you're not responding to weight loss - but that you are still 40 lbs overweight.

(2) You say you're not responding to diet - but that it isn't perfect, just a lot better.

So, can you really say you aren't responding? These things aren't easy, I completely understand that; however, sometimes you can't expect to see results unless you follow treatments all the way.

Yes, possible factors include anatomic, neurologic, endocrine, infectious, inflammatory… but it's only your healthcare provider that can lead you through a differential diagnosis for your situation.

Your doctor has already evaluated you specifically and made recommendations tailored for you. Try your best to follow them all the way to see how you respond. And follow up with your provider along the way for guidance.

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I would first and foremost attempt to lose weight; nevertheless, Endoscopy is not really the the optimal test to diagnose hiatal hernia. You should do a double-contrast Esophagus-Stomach-Duodenal X-Ray.

As for what Gene said re: PPIs, it makes no sense. Their mechanism of action is to inhibit the chemical mechanism that allows the gastric parietal cells to secrete acid (Proton -i.e. ionized hydrogen- Pump Inhibitor).

Regardless, PPIs will never actually cure reflux, just by supressing the acid you prevent complications of ACID reflux (irritation of the esophagus, bruxism, etc).

Barium Swallow

Acid Reflux Patient Info

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Does your reflux come with certain foods but not others? One often overlooked cause of acid reflux is insufficient acid production in the stomach rather than excess. Sometimes this is caused by malnutrition and sometimes by other imbalances in your intestinal floral. In either case, PPI's would do you no good because what your body really needs is support in acid production rather than suppression of acid production.

If you want to test this possibility, try taking some Betaine HCl (I found mine on Amazon). The results could be painful if you weren't lacking stomach acid in the first place, since now you have even more acid to deal with, but it's a quick way to test/rule out this possibility.

It's also possible your LES just needs time to retain its ability to contract and close itself in order to prevent reflux. For that I recommend some self massage around the abdomen.

I myself never had great success with PPI's and reflux, since my body would just adjust to the inhibitors and produce more acid than before, thereby negating the intended effect. Over time it was improving my digestion that helped (nutrition, enzymes, prebiotic and probiotic support)

Further reading:

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  • Thanks @Gene Zhang (+1) - no certain foods do not trigger it, it comes and goes but is usually present and painful. I eat a fair amount of good healthy food and also take multi-vitamins so I highly doubt malnutrition is at play (I've also had blood panels done to confirm this). A few followup questions if you don't mind: (1) Besides this DIY "take home test" of Betaine HCL, are there any tests my GI doctor could order to test for insufficient stomach acid production? – smeeb Nov 5 '15 at 12:11
  • Also, (2) do you know what would cause the LES to suddenly (5 months ago) start requiring more "time to retain its ability to contract and close itself in order to prevent reflux"? In other words, if its not insufficient acid production, and it is the second item you mentioned (LES dysfunction), then what might be the cause there? – smeeb Nov 5 '15 at 12:11
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    Hi and welcome. This site requires sources which support answers We appreciate that it's a burden; consider how appreciated sources on answers to your own potential questions would be. Please see the site tour and the help sections for more information about the site. Finally, please edit your holistically attractive but unproven answer (you're prescribing acid for acid reflux? Is there any scientific evidence to back it up?) or this answer risks deletion. – anongoodnurse Nov 5 '15 at 14:45
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    @smeeb - This is your body! Be wary of ingesting stuff without reason. Your doctors confirmed the presence of GERD. This is a random person on the internet's unsupported advice. I would humbly suggest that you wait for supporting references or read something reliable about Betaine HCL and GERD before upvoting this answer. – anongoodnurse Nov 5 '15 at 15:01
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    Thanks @anongoodnurse (+1) - yes I would never ingest anything without an MD telling me to do so, which is why in my first comment above I am asking for what test I could ask my GI to order that might confirm this "insufficient acid production". Also, I am a member of many SE sites (most notably StackOverflow and Programmers) and it is general SE etiquette it upvote anybody who takes the time to answer your question, which is why I upvoted it. Anyone who finds this question and then blindly ingests chemicals off of Amazon without consulting their MD is a good Darwin Award candidate ;-) – smeeb Nov 5 '15 at 15:37

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