Why did GI order upper endoscopy?

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RainBaby
Regular Member


Date Joined Feb 2009
Total Posts : 41
   Posted 12/20/2009 2:38 PM (GMT -6)   
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.
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC86006/)

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.

So ...
-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?

RainBaby
Regular Member


Date Joined Feb 2009
Total Posts : 41
   Posted 12/20/2009 2:57 PM (GMT -6)   
To add some more information:

False-negative rates for H. pylori biopsy while on PPIs range from 13% to 56%.

"Variable rates of false-negative H. pylori biopsy results or breath test results have been reported in previous studies of patients taking proton-pump inhibitors [2-11]; these rates range from 13% to 56% [8].

In the largest of these studies, Hui and coworkers [8] performed histologic assessment of H. pylori status in patients with duodenal ulcers before and after 4 weeks of treatment with omeprazole (10 mg/d or 20 mg/d) or ranitidine (150 mg twice daily). Comparison of the pretreatment and post-treatment results showed that H. pylori-negative status increased by 38% in the 10-mg/d omeprazole group (n = 77), by 56% in the 20-mg/d omeprazole group (n = 76), and by 1% in the ranitidine group (n = 79)."

My boyfriend is on 20mg TWICE a day omeprazole (any thoughts as to why such a high dose? Isn't 20mg/d usually sufficient? He was asymptomatic on 10 b.i.d. but his doctor had him increase it for some reason), so that would suggest a ~50% false negative rate for H. pylori biopsy while on his current treatment.

But get this ... in another study, it was found that omeprazole caused only a 4% false negative rate for the urea breath test. That's not so bad! If that's the case, he could just do a urea breath test to check for H. pylori.

http://www3.interscience.wiley.com/journal/118774293/abstract?CRETRY=1&SRETRY=0

"Methods: Patients positive for Helicobacter pylori by urea breath test were randomized to receive either omeprazole 20 mg/day, pantoprazole 40 mg/day, lansoprazole 30 mg/day or esomeprazole 40 mg/day for 14 days. A repeat breath test was performed on day 14 of treatment.

Results: One hundred and seventy-nine patients, mean age 45.8 ± 16.8, completed the study. Treatment with omeprazole or pantoprazole prior to urea breath test (UBT) was associated with low false negative results, while lansoprazole and esomeprazole caused clinically unacceptable high false negative rates (pantoprazole 2.2% vs. lansoprazole 16.6%, P = 0.02, vs. esomeprazole 13.6%, P = 0.05; omeprazole 4.1% vs. lansoprazole 16.6%, P = 0.05)."

And get this - if you give the patient some citric acid to acidify their stomach prior to the urea breath test, you can get more accurate results even while they are on PPIs (makes sense, right?): http://www3.interscience.wiley.com/journal/118966110/abstract

But on the other hand, maybe he doesn't have H. pylori at all. Maybe it's just something causing twinges/tightness/pain in left side in what the doctor said was the stomach area, something that resolves on PPIs. What are the options?

Note: I have low stomach acid production (hypochlorhydria) and I sometimes supplement with Betaine HCl (basically additional acid for digestion). If I take too much, I get small sharp pains in the same area where my boyfriend had pains, left side under ribs in basically the stomach area. So I could imagine that excess acid might cause some stomach pains, even in the absence of H. pylori or an ulcer. For me, it goes away quickly if I take deglycyrrhized licorice, the so-called "lining tamer," which soothes the stomach lining.

What are ulcer symptoms anyways?

RainBaby
Regular Member


Date Joined Feb 2009
Total Posts : 41
   Posted 12/20/2009 3:06 PM (GMT -6)   
Additionally, shouldn't an antibody test remain positive even while on PPIs?

"Serologic or whole-blood antibody tests are commonly used to screen patients for H. pylori because they are easy to use and inexpensive. However, if a patient has been treated for H. pylori infection, antibody test results can remain positive for years and are therefore not generally useful in the assessment of post-treatment H. pylori status [14]."

Maybe he could be tested again? Testing twice decreases the false negative rate.

RainBaby
Regular Member


Date Joined Feb 2009
Total Posts : 41
   Posted 12/20/2009 3:10 PM (GMT -6)   
Anyways, his symptoms do not seem similar to ulcer symptoms. (no pain in chest, no pain at night, nothing that feels like heartburn)

Instead it sounds more like gastritis: http://www.umm.edu/altmed/articles/gastritis-000067.htm

"A number of things can cause irritation, including: ....
Alcohol use ....
Coffee and acidic beverages" (he used both frequently)

Gastritis treatment is:

Treatment:

Treatment of gastritis depends on the cause of the problem. Some causes may resolve by themselves over time, or may be relieved by stopping the ingestion of irritating substances, such as alcohol, tobacco, and aspirin. Some dietary changes will no doubt be recommended, although the bland diet often prescribed in the past is no longer thought to be necessary. Medications are often necessary to relieve symptoms, eradicate an infection such as H. pylori, and prevent or treat complications from gastritis, such as an ulcer.
Lifestyle

The cure for gastritis caused by ingesting irritating substances is to stop the long-term use of these substances, which may include:

* Alcohol.
* Tobacco.
* Acidic beverages such as coffee (both caffeinated and decaffeinated), carbonated beverages, and fruit juices with citric acid.
* NSAIDS, such as aspirin and ibuprofen -- switch to other pain relievers (like acetominophen)
* Eat a fiber-rich diet.
* Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori.
* Avoid high fat foods (at least from animal studies, high fat foods increase inflammation in the stomach lining).

RainBaby
Regular Member


Date Joined Feb 2009
Total Posts : 41
   Posted 12/20/2009 3:40 PM (GMT -6)   
I'm just having a hard time thinking of what they are looking for.

He had gastric-related pain relieved by food, antacids, and PPIs. So ... do we need any further diagnosis to say there was some sort of acid-related gastric irritation?

H. pylori testing can be done without endoscopy.

There are no alarm signs or age to recommend endoscopy, and the fact that the symptoms resolve with PPIs also suggests the problem is not serious (not some persistent pain from cancer or something).

And given that it's GI issues relieved by reducing acid, isn't the tretament what he's already on, lifestyle changes and a few months of reduced acid?

I don't see what further information they are looking for from endoscopy. Whether or not they see anything, they will keep him on PPIs until the LPR has healed. And whether he should take H. pylori antibiotics could be determined non-invasively.

couchtater
Elite Member


Date Joined Jul 2009
Total Posts : 14475
   Posted 12/20/2009 7:39 PM (GMT -6)   
Welcome rainbaby,
It's wonderful that you care so much for your boyfriend.
The endoscope is good to find out if there is any physical deformaties that are contributing to your boyfriend's GERD like a hiatal hernia or else.
I was sedated for my two endos and there was nothing to them.

Joy

couchtater
Elite Member


Date Joined Jul 2009
Total Posts : 14475
   Posted 12/20/2009 7:39 PM (GMT -6)   
Welcome rainbaby,
It's wonderful that you care so much for your boyfriend.
The endoscope is good to find out if there is any physical deformaties that are contributing to your boyfriend's GERD like a hiatal hernia or else.
I was sedated for my two endos and there was nothing to them.

Joy
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