Posted 12/20/2009 1:38 PM (GMT -7)
My boyfriend was diagnosed with LPR by nasal endoscopy (or whatever that one is called).
The ENT put him on omeprazole, which he has been taking for 2 months. It has eliminated the throat symptoms as well as a pain he used to feel in his left side, in an area his doctor said was his stomach.
He tested negative on an H. pylori antibody test before starting on PPIs, but there's about a 5% false negative rate for this antibody test.
Could it happen that he had gastric pains, irritation, or even ulcer (that were relieved by food, antacids, and PPIs) but that weren't related to H. pylori (since he tested negative in an antibody test)? Before getting diagnosed with LPR, he used to drink a LOT of coffee and espresso and alcohol.
Now, he is scheduled for upper endoscopy next month. I am trying to understand what the doctor hopes to get from this test. How might this test change treatment?
Here is my thought:
Diagnosis of H. pylori is less accurate in patients who are on PPIs.
Also, PPIs completely eliminate his symptoms.
Shouldn't he wait until he is off PPIs for further H. pylori testing, so as to see if the problems go away with PPIs only, or to get a more accurate test result? Sometimes PPIs are sufficient treatment for H. pylori anyways (they have demonstrated antimicrobial activity against H. pylori--http://www.aafp.org/afp/2002/0401/p1327.html).
If the main purpose of the endoscopy is to check for is H. pylori, ... why not use breath or stool tests instead? and if those are less sensitive on PPIs, then won't endoscopy also be less sensitive while on PPIs?
I know endoscopy isn't that bad ... I just want to ask questions before having my boyfriend subjected to demerol, gag reflex, missing work, and people shoving stuff into him .... I don't know what the doctor is looking for (peptic ulcer?) or how the test would alter treatment (still PPIs, right?).
Btw, he has no heartburn symptoms. Sometimes endoscopy is indicated in cases of LPR with heartburn to check for esophageal changes, but he has no hearburn.
Also, I saw that the American Gastroenterological Association 2005 recommends upper endoscopy only for patients with dyspepsia who are 55 or older or who have alarm symptoms. My boyfriend is only 24 and he does not have any of the alarm symptoms. Why are they ordering an endoscopy?
I also saw the following: "however, a test-and-treat strategy is recommended but for patients with undifferentiated dyspepsia who have not undergone endoscopy. In the office setting, initial serology testing is practical and affordable, with endoscopy reserved for use in patients with alarm symptoms for ulcer complications or cancer, or those who do not respond to treatment. Treatment involves 10- to 14-day multidrug regimens including antibiotics and acid suppressants, combined with education about avoidance of other ulcer-causing factors and the need for close follow-up. Follow-up testing (i.e., urea breath or stool antigen test) is recommended for patients who do not respond to therapy or those with a history of ulcer complications or cancer.
[If I were the doctor, I would have him take PPIs for a few months, alter his lifestyle risk factors, and take supplemental B12 and other vitamins decreased by PPIs, maybe use pepto bismol or DGL and glutamine for stomach lining, then taper off slowing using antacids in case of rebound acid secretion (due to hypergastrinemia), then see if he is symptom-free. If so, success, and he can go about his life. If not, urea breath test, and H. pylori treatment if needed, or more PPIs, or endoscopy, but only after initial therapy shown ineffective.]
Mostly, I'm just thinking if endoscopy is going to be done only once, it might yield more information if it is done after the course of PPIs, after he tapers of PPIs, since he is having no symptoms while on PPIs.
- - -
There was a similar issue a few months ago, where he had classic hemorrhoids symptoms (tiny bit of bleeding after straining ONE TIME) and a hemorrhoid that probably could have been diagnosed with anoscopy in a matter of minutes, but the test-happy doctors sent him for a sigmoidoscopy, which was a very involved procedure, and they found ... (surprise) a healing hemorrhoid that could have been viewed with an anoscope (nobody thought to do that less invasive test first, and they didn't care that the bleeding happened only once--they just sent him for the sig).
I don't want my boyfriend to be unnecessarily poked and prodded just to cover doctors' asses in liability. We live in Boston and my boyfriend's doctors (mostly Harvard Med grads) seem to be test-happy. My own PCP went to medical school in Lebanon and is far more conservative when ordering tests, saying he doesn't want to subject me to invasive procedures unnecessarily.
-What could be gained by endoscopy now?
-Would it be ok for him to postpone endoscopy until after tapering off PPIs? Any drawbacks to doing that?