Causes of GERD when not responding to weight loss or PPIs
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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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:
chriskresser.com/what-everybody-ought-to-know-but-doesnt-about-heartburn-gerd/ http://digestivehealthinstitute.org/2014/07/10/h-pylori-low-stomach-acid-gerd/ www.therootofhealth.com/heartburn-acid-reflux/ http://www.physiciansweekly.com/proton-pump-inhibitors-overuse/ www.health.harvard.edu/digestive-health/do-ppis-have-long-term-side-effects
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.
You have reduced your weight, but are still overweight/obese.
Intra-abdominal pressure is associated with reflux. This also includes tight clothes, posture.
(2) You say you're not responding to diet - but that it isn't perfect, just a lot better.
You mentioned what you eat, but not how much you eat at once, what time of day, your posture.
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.
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).
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