GERD and Anxiety - food for thought

[Dr_Shipko]

Almost everyone with panic disorder or stress induced anxiety is going to have GERD. On the other hand, people with untreated GERD often develop anxiety.

In either case, treatment of anxiety is helpful to GERD. My research indicates that GERD secondary to anxiety is probably due to duodenal-gastric bile reflux. As such, I treat it with Xanax (which inhibits CCK and therefore bile release) and Carafate which binds bile and forms a bandage over eroded gastric mucosa.

Xanax is a tricky drug to work with, and few doctors understand it anymore (the last educational lecture on it was over 15 years ago). The SSRIs have a whole set of problems that make them a second choice to Xanax for any panic anxiety. The PPI's seem to be less specific for bile GERD -- motility stimulators are a problem in anxiety related GERD.

I will be happy to share what I know with all of you.

http://www.algy.com/pdi/research.html

[tricia]

Hello DR Shipco You say Anxiety as a primary cause of gerd is probably due to duodenal-gastric bile reflux.

Would you reccomend that one with anxiey/ panic be tested for excess bile? or are you primarily going on theory?

Also what about the people who have been on xanax for a few years before developing GERD? Shouldn't this drug protect them from excess bile to a certain degree?

And medical publications name xanax as an exacerbater of GERD , so isn't there kind of a double edged sword here? How can you use something to treat in which gerd sufferers are advised to stay away from due to weakening of the LES? Thank you

[GW]

I'm so pleased that you've decided to take time out of your very busy schedule to come and join ranks here with our esteemed moderator, Hawk, in his quest to help others with all kinds of heartburn problems.

I have such high regard for you bringing the start of some ground-breaking discoveries in the field of anxiety related GERD. Your studies came to me (I believe providentially) through a guy by the name of Hallsy who posts here regularly. I was so ready to throw in the towel and go get surgery when at the last minute....... I tried a script for the "entry level" dose of Alprazolam for my anxiety. I found almost instant relief in both GERD pains and the panic attacks I was starting to have on a regular basis.

As far as my story, Hallsy's and few others here, (not to mention quite a number of my friends and relatives) I could care less if this work isn't in the Blessed Halls of Medicine.....yet. We've all benefitted greatly and have had nothing but success in rooting this out as our best plan to combat this horrible disease.

From a healed Anxious GERDie: Thank you, thank you, thank you......:p for validating my own discovery in the healing I've received.

I'd love to hear about a few of the success stories you've seen in your own practice concerning anxiety based GERD.

geeDub

[awalker]

I too am gald that you joined in for this discussion. I do have a question. GW pointed out that paxil, which is what I have been taking since I had a backlapse in my GERD is actually an antidepressant, not anti-anxiety. Last year, when I was having so much trouble, and in a great amount of pain, I was given the Xanax to help calm me enough to sleep. I didn't take it very long, but did continue with the paxil for probably 2 - 3 months. I guess I am just a little confused as to which one would do the most good. I do not like taking these types of drugs, infact I usually only take half the dosage. But, I can tell that my stomach and chest do not hurt near as badly, nor does my esophagus hurt. I just want to get back to where I was before, 1 PPI a day, and no other meds.

[Dr_Shipko]

Tricia:
I don't recommend that people with anxiety based GERD get tested for bile. I used to do this when I was first doing research on the project. After I studied enough patients (and it is not cheap or easy to evaluate for duodenal gastric bile reflux) I concluded that it was more appropriate to treat the patients and reserve evaluation for treatment failures.
I don't really have an answer for you about people who have been on Xanax for a few years prior to developing GERD. This is not very common in my practice. Usually patients present with anxiety and have not been on Xanax or other BDZs prior to seeing me.
The issue of Xanax and the LES is a good one. Fundamentally I consider the problem to be duodenal - gastric bile reflux and not a problem with the LES. When bile reflux is stopped then whatever effects that Xanax may have on the LES are rendered far less significant.

[Pete]

Dr,

In your opinion could the problem of excessive belching be related to bile reflux? I don't believe I have anxiety but upon endoscopy my GI did see a lot of bile in my stomach. Thank you

[Dr_Shipko]

First of all, regarding bile seen on endoscopy, it is not a reliable guide to bile reflux. The act of putting an endoscope into the stomach causes mechanical bile reflux that is not the same as spontaneous bile reflux.

Back when I was working with gastroenterologists, we did see people who belched frequently. These patients all had the same question: "Where is all that air coming from?" Doctors would tell them that they are swallowing air, but the patients knew that this was not the case.

Finally I saw the endoscopy of a patient while they were belching. What was happening was a reverse intussuception. The esophagus was folding in on itself, which sucked down air and when it straightened out the patient belched.

This is not the same as anxiety based reflux. Because it is an alarming symptom it is associated with anxiety, but the mechanism is completely different.

[maxx]

From what I understand about xanax is it is for the short term use as it is habit forming and requires the dosage to be increased to continue working. I think this is why dr dont go with
xanax before other meds. Is xanax the only one that works on the les muscle?

[GW]

Hi Maxx,

I think you may've missed a couple of items in your research. ;) The reason one would take Xanax or any benzodiazapine is to control the Lower Pyloric Sphicter......as a CCK inhibitor. The LPS is the valve that allows for bile to flow into the stomach. The LES (lower esophageal sphincter) is the valve that is between the esophagus and the upper stomach.

As far as I know, any benzo would work. Also, I found that I only needed the "entry level" dosage of Xanax 0.25 mg once a day . At only 1/4 of a miligram it is not habit forming. As far as long term use, I don't know at that level. My experience was at three months and a week, I stopped cold and had no withdrawl at all. It's been over a year and I've only needed it a couple of times for panic attacks......not GERD.

G

[tricia]

Xanax relaxes the LES muscle, much like alcohol - it also weakens the LES- but as DR Shipco pointed out above........

When considering the problem to be bile reflux, and not a problem with the LES, - whatever effects xanax may have on the LES are rendored far less significant than the problem of bile reflux.

But Dr Shipco, can you please explain to people -- simply that if they feel anxious this does not mean they are to conclude that they have bile reflux . I've noticed in the past, many people have made this assumption.

Aren't you talking about this abnormal bile flow occuring only specifically with diagnosed anxiety panic disorder? And how is this disorder diagnosed properly? With a 21 questions test? And is this disorder life long management? And can this disorder be treated with very low doses of xanax?

Also in the average GERD sufferer, who may feel a little anxious, how would Xanax benefit them? My take would be it acts as a muscle relaxant, calms nerves, because we know stress exacerbates symptoms, until the disease's symptoms ease up, or go away, because as we know, many gi diseases - seem to have periods of exacerbation and periods of remission. Would you agree with this analogy?

Thank you very much

[Mel D]

This is very interesting to me because tests show my LES functions perfectly, but I have GERD after eating. Have been diagnosed with panic disorder and depression and am currently on Xanax SR 1mg QD.

I do notice that my symptoms are worst about an hour before my scheduled dose of Xanax. But I'm not sure if this is due to after-effects from eating lunch, the Xanax wearing off, or because it's late afternoon and the stresses of the day have been building up.

My doctors have all recommmended Nissen fundoplication, but I'm reluctant to undergo that if my LES functions normally with normal esophageal motility.

Thank you doctor, for taking the time to visit this site.

[GW]

Hi Mel,

Just wanted to wish you the best in recovery from your particular form of this junk. I always hope for all my friends here on HH that they get the same results as I did. I know I am extremely fortunate to have had the results I did. Nevertheless, I do hope you find the path that leads to the end of your "GERD Journey".

Later days,

geeDub

PS.....maybe chat atcha tonite on the the ol "chat line wednesday".

[Pete]

Dr.

That is interesting what you found on endoscopy with the belch. In your opinion, is there anyway to treat it?

Thanks so much

Pete

[Mel D]

Originally posted by GW
Hi Mel,

Just wanted to wish you the best in recovery from your particular form of this junk. I always hope for all my friends here on HH that they get the same results as I did. I know I am extremely fortunate to have had the results I did. Nevertheless, I do hope you find the path that leads to the end of your "GERD Journey".

Later days,

geeDub

PS.....maybe chat atcha tonite on the the ol "chat line wednesday".

Parden me for being dense, but what is this chat Wednesday? On this site?

PS I'm still plugging along, still have symptoms, still on meds, waiting to see 2 new doctors. One's a GI doc who performs the Endocinch, and the other is an MD who treats the whole person and really tries to get to the bottom of your problems. I'm seeing him in two weeks. yay!

PPS School is keeping me SUPER busy! I never have time to come online! But I do like to check in here when I can.

Mel

[GW]

Originally posted by Mel D
Parden me for being dense, but what is this chat Wednesday? On this site?


Mel


Oh.....I thought you knew. Go to the original "home base" of Hawk's site....down at the bottom of the page. Click on "Heartburn-Help.com".....then click on the "Chat". You'll figure it out from there. It starts at 9pm east coast time on Wed. nites and lasts an hour.

http://www.heartburn-help.com/irc/default.htm

Have fun!

G

[Dr_Shipko]

In reply to the points that Tricia brings up...

People who are anxious should not automatically conclude that their heartburn is due to bile reflux.

My research was conducted only on patients with panic disorder so my comments about bile reflux are specific to people with panic disorder.

Diagnosing panic disorder is not as easy as it might seem. While the DSM - IV has a checklist of symptoms, the actual condition is more complicated. Panic disorder tend to be episodic and recurrent at various times in a person's life although some people have limited symptoms on a chronic ongoing basis. Because the condition is episodic, I favor episodic treatment rather than long term ongoing treatment. One can use very low dosages of Xanax in some patients.

People with primary GERD and many other GI problems do find that stress aggravates their condition. It makes sense since the gut has such an intimate connection with the nervous system. Xanax can act as a stress reliever -- but the addictive properties of the drug make this a risky strategy,

For more information on the diagnosis and treatment of panic disorder, I have written a book on the subject, Surviving Panic Disorder which can be found at http://www.anxiety-panic.com/shipko

[maggie c.]

Finally I saw the endoscopy of a patient while they were belching. What was happening was a reverse intussuception. The esophagus was folding in on itself, which sucked down air and when it straightened out the patient belched.

This is not the same as anxiety based reflux. Because it is an alarming symptom it is associated with anxiety, but the mechanism is completely different.

Dr. S: What would this reverse intussuception feel like to the person having it? I experience two types of esophageal sensations daily--one feels like mice running up my esophagus, top-of-the-stomach to mid-chest height. The more disturbing one feels like a pounding or thumping just south of my breastbone, where the esophagus meets the stomach. Neither produce actual pain, and both types can be relieved by getting a burp up, though sometimes I can't force one up. I am exploring the anxiety angle of all this now & that's how I found your comments.

Thank you very much!
Maggie C.

Thanks very much!

[Grandma Barbie]

I have a 16 year old granddaughter who has been dealing with Gerd since she was in the 2nd grade. All through grade school she was treated as if she was faking stomach pains. Even her doctors said "She should be in school" and that is what we did - forced her, sometimes dragging her, to be in school. We finally found a doctor who put together a combination of drugs that gave her complete relief from her Gerd and from IBS. She was fine for about 1 1/2 years when propulcid, the drug that was helping her, was taken off the market. Since that time she has been given numerous drugs that have not helped and have caused side effects, sometimes so severe she ended up in the ER. Her anxiety has increased 10 fold and she has not attended school since the 8th grade and is getting homebound instructions. She had her 5th endoscopy two days ago and the doctor is recommending Nisson. She also has delayed emptying of the stomach and they may recommend Pyloroplasty. She has been seeing a physiatrist but not making any headway with the anxiety because of the severe Gerd. I find it interesting that when the subject of anxiety was approached the medical doctors always answered - she should be in school - see a physiatrist!!

She is taking Rimiron at night to help her sleep, otherwise she is up most of the night with her Gerd symptoms. The Rimiron makes her nauseated for most of the next day.! Her mother is very anxious about the surgery and we are looking for some encouraging words as to the rate of success and the effect a successful surgery will have on the anxiety. Any thoughts on her situation?

Grandma Barbie

[SRasband]

Seeeee????? I am so happy I found this site. I have been trying for years to convince my gastro that my problem was in the biliary system and not the stomach. What it feels like is that my liver (had the gallbladder out 20 some years ago) just keeps working all nite long and that I am getting reflux back into the stomach that then is kept working to balance the ph. What seems to 'put the biliary/digestive' system to sleep, is a small dose of Ativan before I go to bed. So, to me this is brilliant and incredibly validating. I have complex PTSD and chronic anxiety that has always gotten lodged in my GI systmem. The valves, all of them including the sphincter of Oddi seem to spasm from time to time and that is painful and problematic, especially when it is the LES and food doesn't want to go into the stomach. But I have had ALL the diagnostics and the only thing that shows up is 'non-ucler gastritis', AKA beats the hell out of me. I tell you, years and years and lots of money and 'non-ulcer gastritis'. Tried the PPI's, don't work and just inflame the GI tract. Pepcid AC works in a pinch and don't need much.

Glad this forum exists,

Stephanie

[rocket]

I stumbled across this post: http://www.skin1.net/talk/forums30.cfm/7601

Here's a user who, presumably has never been to this board, is finding relief w/ xanax.

[obinna]

What is Duodenal gastric bile reflux . Is it the same as Peptic Ulcer in the duodenum ? i want to know because i was diagnosed with Peptic Ulcer in the duodenum and among my symptoms are constant belching ,salivation and pain in below my rib bone and my sides.

obinna

[daw]

What is Duodenal gastric bile reflux . Is it the same as Peptic Ulcer in the duodenum ?
Hi obinna, Duodenal gastric bile reflux is when the bile in the duodenum goes past the pyloric sphincter and gets into the stomach. It is not a Peptic Ulcer. If it happens to go past the lower esophageal sphincter (LES) then it is called Duodenal gastric esophageal reflux.

[obinna]

Daw like i stated in the site i was diagnosed with ulcer in a kind of Duodenal ulcer.But i dont exactly know what is reflux .PLease could you explian to me in laymans terms what is reflux.The things that happens to me is that i belch a lot even when i dont eat. I also have water brash with pains below my rib bone area and some heat sensation in my chest ,sides and back area.
I also experience regurgitation especially when i belch.
can you link these symptoms.

Obinna.

[daw]

obinna,
Reflux (gastroesophageal reflux or sometimes called acid reflux) is when the stomach contents come up into your esophagus because for some reason your muscle tone between your esophagus and stomach is not strong enough to keep the stomach contents in the stomach. Regurgitation of your stomach contents (when you feel liquid coming up into your mouth, like when you burp) can be considered reflux. Some people feel heartburn when and after this happens but not everyone. The liquid that is refluxed up from your stomach is irritating the esophagus and sometimes even the throat, voicebox, lungs and sinuses. Some people get all different sorts of feelings including strange pains when this happens. Some people feel nothing at all.

A duodenal (first part of the small intestines) ulcer (also called a peptic ulcer)has typical symptoms of gnawing, burning, aching, soreness, an empty feeling, and hunger. The pain is steady and mild or moderately severe, and it is usually located just below the breastbone. It is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. The most common reasons for peptic ulcers are infection with H.Pylori bacteria and the use of certain drugs like aspirin and other anti-inflammatory drugs.

You can have reflux and/or an ulcer. You don't have to have both, and reflux only causes ulcers that are found in the esophagus.

[obinna]

Thanks Daw but i would like you to explain this statement you made "You can have reflux and/or an ulcer. You don't have to have both, and reflux only causes ulcers that are found in the esophagus " I really would like you to explain that for me.Meanwhile i meet a doc who gave me some drugs .the doc is not a GI or a Gastrologist just a GP. I would find out the name of the drug and let you know too.
Obinna.

[daw]

.....I would like you to explain this statement you made "You can have reflux and/or an ulcer. You don't have to have both, and reflux only causes ulcers that are found in the esophagus ".....
First keep in mind the simple definitions of the words "reflux" and "ulcer" The word "reflux" means "a flowing back". With GERD, the acid "flows back" up into the esophagus. Ulcer is an open sore. It can happen anywhere on the body.
You can even get them on your skin. I'm sure you've heard of bed sores...they are also called pressure ulcers.

GERD (gastroesophageal reflux) and Peptic/Duodenal Ulcers are two different diagnoses. For instance I have GERD but I've never had a Peptic/Duodenal ulcer. Some people only have a Peptic/Duodenal ulcer and never have GERD.
Some people have both or many other GI diagnoses. But remember, just because you have one does not mean you will get the other one.

When a person has GERD, they can sometimes get an ulcer (a sore) in their esophagus because the stomach acid is "refluxed" up into their esophagus and then eats away at the esphageal tissues causing an ulcer (sore). Not everybody gets sores in their esophagus from acid reflux.

When a person gets a sore in their duodenum it doesn't have anything to do with their esophagus. The esophagus is nowhere near (relatively speaking) to the duodenum. Now, as I stated, you could be a person that has the misfortune of having both problems. Unfortunately many people with GI problems have many GI diagnoses.

I hope this clears up some of your questions. If you have more questions try posting a new thread. Maybe someone can explain and answer your questions better than me. I hope your new medication helps. Let us know how you are doing. daw