Dr. Ajeet Kumar
Medical Gastroenterology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I have suffered from reflux for over 10 years now, but usually quite manageable. It waxes and wanes. There are periods where I can have no symptoms, eat trigger foods without problems, and take Gaviscon now and then, and there are periods where I have to take 40 mg of PPI daily to keep it in check.
However, it got worse about six months ago. Even with 40 mg PPI's, I still have reflux every day. It is not so bad, and it still has good days alternating with lesser days. An endoscopy revealed no anomalies. No H.Pylori, but did reveal a lower oesophageal sphincter that does not close properly.
Yesterday, however, I got the diagnosis of mild gastroparesis after a 2-hour gastric emptying test (T1/2 is 82 minutes and at 1-hour mark, 66% of the eggs and bread meal still present, at 2 hours, only 22% was left). We also did a Barium swallow that revealed reflux, but the liquid passed through my stomach at a normal speed. No obstructions were detected.
I do not throw up. I barely ever even need to throw up, and my appetite is more or less intact. My main symptoms are heartburn and reflux that got worse about six months ago abruptly. I have no diabetes, not overweight, have normal blood pressure. I am a 38-year-old male in general in good health. I did not have any abdominal surgery either. The only medication I take are beta-blockers (2.5 mg of Bisoprolol daily) due to having had an arrhythmia and 40 mg of Omeprazole. My heart is also completely structurally fine; it was all checked earlier this year (no clogged arteries, no damage, never a heart attack. My arrhythmia was purely a problem with electrical signals, probably a genetic thing).
The current reflux symptoms are manageable, and I can tolerate them. However, what did worry me and kept me out of my sleep last night, was that I read a lot of horror stories on the internet from patients whose gastroparesis progressed over time and got worse, leading to malnutrition and having tube-fed. This freaked me out. I know the internet is an advisor, and I should not have googled it. But I am still worried about this whole progression thing, so I would instead ask an actual doctor.
Is gastroparesis something that typically worsens more and more up to a point where you become malnourished and need to be hospitalized?
Hello,
Welcome to icliniq.com.
I have read your history and seen the report of gastric scintigraphy (attachment removed to protect patient identity).
You do not have gastroparesis, a fraction of 25% at 2 hours post-meal within the stomach is a normal finding. Ideally, it should have been done for four hours. And a fraction of less than 10% at four hours essentially rules out gastroparesis.
But while looking at the scintigraphy images and of very well flowing of contrast through the stomach and in the small intestine at two hours is quite reassuring. Otherwise, the gastroparesis patients had completely dampened contrast within the stomach even after four hours of the test meal.
Since you do not have gastroparesis evidence, I think there is no need to discuss whether you would develop any complications.
Please remember in gastric scintigraphy we see two to three things.
1. We see the transit time of the contrast from the stomach to the small bowel, which is normal in your case.
2. In abnormal hold up of contrast (meaning there is more than 10% contrast residue in the stomach at the end of 4-hour of test meal), we then look up the primary site of the contrast hold up. For example, in functional dyspepsia it is antrum, in GERD patients it is fundus (proximal body of the stomach), and in gastroparesis, a generalized meaning retention across all parts of the stomach namely fundus, body, and antrum is seen. This is just for your knowledge. Otherwise, it is applicable to you since your study is normal.
Your recent breakthrough symptoms are basically due to the natural history of GERD (gastroesophageal reflux disease). The people often have recurring symptoms, but thankfully it is still manageable with an increasing PPI dose (proton-pump inhibitor). You can increase up to 80 mg in divided doses even. What concerns me more is the development of the Barretts esophagus (BE). For this, I want to see your endoscopy report, which has recently been done. And want to know if the endoscopist thoroughly evaluated you for that and ruled it out.
I hope this helps.
Patient's Query
Thank you doctor,
Unfortunately, I do not have access to the images of the endoscopy. I can request them to the doctor. However, I had the gastroenterologist and my general practitioner look at it, and both noticed no signs of lesions in the esophagus.
The report says this (translated).
Premedication : 5 mg Dormicum en 2 amp Buscopan iv.
The esophagus shows normal mucosa and expansion.
The cardia shows no hiatal hernia but is permanently open.
The mucosa, folds, and expansion of the fundus and the corpus of the stomach show no anomalies.
The antrum is intact.
There is a sharp angulus.
The pylorus shows easy passage.
The bulbous shows no lesions.
The second and third parts of the duodenum are normal.
Hello,
Welcome back to icliniq.com.
Can you arrange the images if possible? Otherwise, the report itself is self-explanatory and does not show any sign of Barrett's esophagus. Otherwise, they would have mentioned it since it is an essential finding with that long history of GERD.
You should increase the PPI (proton pump inhibitor) TO 80 mg whenever such breakthrough symptoms occur.
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