The Heartburn That Wouldn’t Quit

Dierdre had written “I want to get off my heartburn medicine” on her WholeHealth Chicago intake form. This, by the way, was a tele-med appointment. I’ve actually never met her in person. We changed Dierdre’s name to respect her privacy, but her story is worth sharing.

Dierdre was in her 30s and had been working at home at one of the many jobs people can do sitting at a laptop, listening to Spotify except during Zoom meetings and today’s visit.

Her medical history provided some clues to the issues at hand. She’d been reminded by her mother quite a few times that she’d been a difficult baby, with lots of colic, diarrhea, and spit-ups until the pediatrician advised eliminating dairy products. Doing this also stopped her ear infections in their tracks.

When Dierdre was a few years older, she’d been able to start eating some dairy products again, but she developed issues with eczema and, a while later, mild asthma. Skilled with an inhaler by age six, Dierdre’s symptoms slowly settled down so that by her teens she was left with seasonal allergies and rare eczema flare-ups during her PMS days.

By her 20s, allegedly the best decade for all of us when we look back on our lives, Dierdre thought she was out of the woods.

But then her heartburn began

She went online, read about GERD (gastroesophageal reflux disorder), and tried one of the many proton pump inhibitors (PPIs), a group that includes Nexium and Protonix. Dierdre told me that after a year, she’d tried them all, but she also developed some other symptoms along the way. Food felt “stuck” as it traveled down to her stomach. She had a persistent discomfort in her chest. But mainly she wasn’t enjoying eating anymore.

Dierdre said that even though the PPIs weren’t giving her 100% relief, they were better than nothing so she’d been reluctant to stop them altogether. When she went to her primary care doctor, he prescribed an extra-strength PPI (Dexilant), which actually did seem a little more potent, but coverage for it was later denied by her insurer, who balked at the $10-per-pill price.

Her doctor told her that when she found the right PPI and avoided the foods that seemed to trigger her symptoms, she could stay on the PPI for the rest of her life.

Dangers of PPIs

What finally pulled the trigger on PPIs altogether was when another of the heartburn meds Dierdre was using, Zantac, was pulled from drugstore shelves because it contained a contaminant that caused cancer.

During our consult, several facts stood out.
–First, the PPIs had never really helped all that much and Dierdre was now into her second year of using them.
–Second, she was convinced that certain foods made her symptoms worse, and not foods that were particularly spicy or notorious for causing heartburn. She just wasn’t sure which ones were triggers.
–Third, she was now having chest pain and upper abdominal pain that wasn’t responding to anything–not antacids, water, or TUMS.

Taking all this together, I suspected she had some chronic food allergies and that frequent exposure to these foods was triggering inflammation in her esophagus, a condition called eosinophilic esophagitis (EoE).

 If you Google EoE, you’ll actually find it listed on the National Organization for Rare Diseases website, which is ridiculous because if there’s one thing that can be said about EoE it’s that it’s pretty common. The problem is that too many people keep chowing down the PPIs (with the encouragement of their doctors) and doing this makes the condition less likely to go away.

More on EoE

The other condition that increases eosinophil counts is intestinal parasites. If a patient comes to us with undiagnosed bowel symptoms, especially chronic diarrhea, and has a high eosinophil count, we think parasites.

A diagnosis of EoE is actually pretty straightforward once the doctor realizes that PPIs are not helping.

I referred Deirdre to the gastroenterologist we use at WholeHealth Chicago, Dzifaa Lotsu, MD, over in Greektown, mainly for his professional expertise and willingness to spend a lot of time with patients discussing his findings. That he is open to integrative medicine is very helpful as well. (It’s also nice to reward yourself with a delicious Greek meal after your visit, since most of the procedures done by a gastroenterologist require fasting.)

Dr. Lotsu used Esophagogastroduodenoscopy (EGD), also called upper endoscopy, to view Dierdre’s inflamed esophagus and took several biopsies, each of which showed many eosinophils when examined under the microscope.

Although the conventional treatment for EoE is to give steroids to reduce inflammation (you literally spray a steroid asthma inhaler in your mouth and swallow it–yes, it tastes awful), long-term steroid use has a host of side effects.

Locating the source

Integrative and functional practitioners prefer a simpler approach. Dierdre would start on an eating program that eliminates the Big Six: dairy, egg, corn, gluten, nuts (including soy), and seafood along with all foods containing chemicals, additives, and preservatives.

At the same time, we sent a blood sample from Dierdre to one of the labs specializing in food allergy testing. Since these tests are occasionally not covered by insurance, we keep an eye on price. I’ve been using US BioTek for more than 20 years. Their testing for 96 foods with antibody response (IgA, IgG, IgE) for around $250 is a relative bargain since insurance rarely covers it.

Elimination diets can be remarkably effective in treating EoE. Dierdre remains on her Big Six elimination and feels dramatically better.

If a few weeks, Dr. Lotsu will repeat his EGD and if the eosinophil presence has declined (which I suspect it will), Deirdre can begin a slow reintroduction of one food at a time to determine which is the real culprit.

Her food allergy blood test might prove helpful in uncovering foods she might not have suspected, but nothing is so accurate, diagnostically speaking, as when the patient herself says something like “Whenever I eat (such-and-such) all my symptoms return.”

Dierdre wanted to get off her heartburn meds, and now she is.

Be well,
David Edelberg, MD