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Gastroesophageal reflux disease, or GERD, is a condition in which the lower esophageal sphincter, a kind of valve at the bottom of the esophagus, fails to keep the acidic, protein-dissolving contents of the stomach out of the throat. The contents of the stomach come up and "burn" the lining of the throat and even the mouth and nasal passages. The damage down by GERD isn't just caused by stomach acid. The digestive enzyme pepsin can break down the intercellular "glue" that keeps the cells in the linings of the throat in place. However, even without pepsin, stomach acid that has a pH below 2 can erode delicate tissues. 

GERD can cause a variety of symptoms. Not just heartburn but also

  • Chest pain,
  • Chronic cough,
  • Asthma,
  • Sinus problems,
  • Ear problems,
  • Tooth erosion, and even
  • Acne

can result from stomach acid's churning upward into the throat. The more often the acidic contents of the stomach come up, the more likely it is that these apparently unrelated symptoms are really due to GERD.

There are a couple of ways to measure how often acid and for how long acid rises from the stomach into the esophagus. One method is the Digitrapper catheter, a long thin tube with a pH meter on the distant end that is threaded through the nose down to the esophagus. The catheter stays in place for 24 hours. The pH meter doesn't take readings constantly. Whenever the patient feels symptoms, he or she presses a button a meter so the meter can do a pH reading, and an external device records the value.

There are several disadvantages to this system. Nobody likes having a tube down his or her nose for 24 hours. The system only takes pH readings when symptoms are noticed. If the patient is busy or sleeping, readings may be missed. Also, the system doesn't give any measurement of how symptoms build up. There's just a single pH reading when whatever is going on becomes so intense that it finally produces a symptom. There's no indication of whether this is a slow leak of stomach acid, such as the pressure of body fat on the stomach might cause, or a sudden upward surge of stomach acid, such as might be due to a defective sphincter.

The Bravo pH meter is a tiny capsule designed to give constant pH readings for not just 24 but a full 48 hours. The gastroenterologist advances the capsule through the mouth, not the nose, and places it in the lining of the esophagus by suctioning up tissue in the lining of the esophagus around the capsule, holding the capsule and the tissue in place for 30 seconds, and then releasing suction and the capsule. The capsule sends a continuous pH reading to a receiver the patient wears around the waist. 

Most patients find that the Bravo pH capsule procedure is (1) a lot easier to deal with than a catheter through the nose but (2) not entirely free of pain and discomfort. There are some things patients can do to make the procedure easier:

  • It's important not to take proton pump inhibitors (PPIs) such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), or esomeprazole (Nexium) for a full week before the test, unless your doctor tells you to take them (usually to see how well they are working). If you have forgotten and taken a PPI, let your doctor know before the test.
  • It's important not to take H2 blockers such as ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), or nizatidine (Axid), or the promotility drug,metoclopramide (Reglan) for two days before the test. If you forgot and took one of these drugs anyway, let your doctor know before the test.
  • Antacids such as Alka-Seltzer, Gaviscon, Maalox, Milk of Magnesia, Mylanta, Phillips, Riopan, and Tums are a no-no starting six hours before the test. If you forgot and took them anyway, let your doctor know.
  • Be sure to eat your regular foods and go about your regular activities while the Bravo pH meter is functioning. It's the only way your doctor can get a useful baseline pH reading.
  • Don't lie down in the middle of the day unless you usually take naps.
  • If you start having chest pain after the capsule has been inserted, call your doctor immediately. Chances are that your doctor will give you a muscle relaxant like lorazepam, but that's a decision that needs to be made by your doctor. Anxiety makes the pain worse, and drugs to relieve anxiety will also relieve pain.

The unfortunate reality is that a small percentage of patients find the Bravo pH meter intensely painful for reasons that can be physical, psychological, or both. If you're stuck with an extremely uncomfortable situation, at least do everything you can to make sure you get useful measurements from the test. The capsule almost always falls off by the end of five days. It may be a difficult week, but your doctor may get the information needed to give you lasting relief from GERD.

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