Heartburn pills not working? You might not have reflux after all ...
MY problems began with a salad. It was November 2014, and just after my meal I felt the distinct sensation of a tomato skin stuck at the back of my throat. Within a week, anything ‘healthy’ — whether it was olives, baked beans or rocket — seemed to be sticking there.
so I saw my Gp and, after antibiotics for a presumed throat infection didn’t fix the problem, was given the diagnosis that would take over the next 18 months of my life: acid reflux.
This is where the acid that normally sits in the stomach moves upwards into the gullet, irritating the soft tissue. It affects one in three people, and usually occurs because the valve that keeps the stomach closed off opens when it shouldn’t.
While I didn’t have the characteristic heartburn, the doctor said it can have more subtle symptoms such as difficulty swallowing, sore throat, wheezing and throat congestion. I ticked all these boxes. It wasn’t until a year-and-a-half later that I learned I didn’t have acid reflux after all. I had another problem with similar symptoms, but a very different solution (and it might help explain why someone’s acid reflux pills don’t work).
but it took numerous doctors, tests, drugs and joyless (and ultimately fruitless) changes to diet and lifestyle to reach this conclusion.
The first step in this lengthy journey was a prescription for omeprazole.
omeprazole is a proton pump inhibitor (ppI) which reduces the amount of acid produced in the stomach.
After two months of taking it nothing had changed, except by now I felt burning in my throat and kept losing my voice in the morning. At this point, I started worrying. I knew that trouble swallowing, persistent sore throat and a hoarse voice are all red flags for throat and oesophageal cancer.
I also knew that long-term acid reflux can damage the oesophagus lining, which can itself raise your cancer risk. I was only 47 and a non- smoker, so I made another doctor’s appointment.
This time she referred me for an endoscopy, where a camera was used to examine my throat. To my relief, although my throat was red and irritated, nothing sinister was detected.
The consultant confirmed the reflux diagnosis and put me on a different ppI called lansoprazole, a slightly higher dose. It didn’t work either.
VArIousdrugs were prescribed over the next year, including Zantac, which reduces acid a different way, and the antacid Gaviscon, which prevents the acid from rising up.
These failed to make any difference. And the various lifestyle changes that I implemented only made my life miserable.
Traditionally, reflux sufferers are meant to do four key things: reduce their intake of alcohol and spicy foods to avoid irritation to the sensitive tissues, eat smaller meals, eat no later than three hours before bed and raise the bed head by 6in so that gravity helps keep the acid down. This sounds so simple, but ends up controlling your life.
I had to sleep in the spare room as we couldn’t work out how my partner could sleep flat and I could sleep raised. And the new sleeping position hurt my back.
I’d spend weeks avoiding alcohol and cooking tasteless meals, to no avail. And when I did allow myself wine or curry the fear that they might be causing awful damage wiped out any enjoyment.
I gave up wheat, dairy and sugar in case my problems were linked to leaky gut (where holes form in the gut’s lining). Again, no change.
by this point, I was on twice the normal dose of lansoprazole and swigging Gaviscon from the bottle when my symptoms woke me at night. so, in may, I decided it was time for the last resort: surgery to tighten the malfunctioning valve.
using my private insurance, I saw marcus reddy, a gastroenterological surgeon at spire st Anthony’s in sutton, and my consultation was a revelation. mr reddy revealed there are at least four other conditions that can cause the same symptoms as acid reflux, but which don’t respond to reflux medication.
‘Drugs for acid reflux are very effective so if a patient tells me they are not working, I have to suspect it’s not stomach acid causing their problem,’ says mr reddy, who also works at the st George’s university Hospital NHs Trust.
mr reddy then referred me for a test called 24-Hour pH manometry. This two-pronged investigation would double check whether I had acid reflux and also help detect other problems.
part one took 45 minutes. It involved sitting upright while a thin wire containing pressure sensors was passed through my nose, down my throat (numbed with anaesthetic) and into my stomach.
Then I was fed water and bread to make me swallow, so that the contractions of my gullet would press on the sensors.
poor contractions can indicate achalasia — one of the four problems that can pass for reflux. Achalasia is where the gullet loses its ability to move food along due to a problem with nerves in its wall.
The pressure- sensor test also checks whether the valve into the stomach is working. With acid reflux, this valve opens too often. but sometimes the opposite happens and the valve does not open enough.
This may be related to achalasia or, rarely, growths. Whatever the cause, the consequence is an irritating build-up of food in the throat.
The first tube was then removed and, for part two, a thinner one was inserted via my nose where it would remain for 24 hours. Thankfully, I was only barely conscious of it and went home so it could monitor my stomach and throat.
Its purpose was to check the acidity in my stomach, and whether acid was reaching my throat. If everything is normal on the acid front, it can indicate the third problem that may cause reflux symptoms: bile acid.
because of a faulty muscle and valve, bile acid can escape from the duodenum into the stomach and into the oseophagus.
‘bile acid is actually alkaline and so acid suppressing drugs won’t act on it,’ says mr reddy.
If these two tests were negative, I might have the fourth potential cause of symptoms — slow gastric motility, where the stomach empties too slowly, causing pressure to build and force open the stomach valve, so its contents spill upwards.
MYINvesTIGATIoN revealed a problem with the valve going into my stomach — it wasn’t that acid was splashing up, but food wasn’t going down properly, so some stuck in my oesophagus.
The technical name was disturbed oesophageal motility.
‘I test about 1,000 patients a year in this same situation,’ says gastroenterologist Dr Anton emmanuel from university College Hospital, london. ‘of those, probably 30 to 40 have a problem with disturbed motility of the oesophagus — the others are a mix of the other problems, or they do have reflux but simply don’t respond well to the drugs and need surgery instead.’ but there may be many more with these problems who have simply never been tested, he says.
‘reflux is enormously common. The drugs given for it are usually successful, so a lot of doctors fall into the trap of assuming that patients who don’t respond are either not taking their medication or need surgery — they don’t think to look for an alternative cause.’
And although tests such as manometry are available on the NHs, he adds they are ‘quite specialist and not done at every hospital’.
so it seems I was lucky. I just needed one more test — another endoscopy — to check whether a stricture, or even a tumour, was behind my valve problem. mr reddy said he could also carry out balloon dilation. This procedure gently tears the fibres in the valve making it open more readily.
Although the exact cause of my misbehaving valve is still a mystery, within days of the procedure all my symptoms had gone.
For the first time in nearly two years I had no sore throat and no clogging mucus. my voice healed, and I could swallow. Having my first ‘fear free’ glass of wine and a curry was heavenly. I still have to eat carefully to avoid debris in my throat. but this means I eat less, and I’ve lost a kilo. Good news all round.