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From: Richard Kaszeta on 24 Sep 2005 19:19
This is one for Howard, if he's still reading here:

In 2001, I had a Nissen Fundoplication done, which resulted in the
near elimination of my acid reflux discomfort, although I still take
20mg Prilosec 1x/day, and rarely have any gastrointestinal discomfort
unless I badly abuse my stomach (large, repeated heavy meals with high
acid content), usually I'm fine.

However, starting in June I started having *severe* stabbing shoulder
pain, primarly in the left shoulder. After a series of X-rays, blood
tests, and a CT scan, my doctors and the radiologist are of the
opinion that the pain is referred pain from diaphragmatic irritation,
but my primary care provider does not think that a consultation with a
GI specialistic is warranted (since my last endoscopy two years ago
was fine), nor is a consult with a surgeon appropriate, and instead
has been treating the symptoms with painkillers (Vicodin). I'm hoping
that a better solution than Vicodin can be found.

Two questions:

1. Can this shoulder pain be caused by something wrong with my
esophagus, stomach, or the results of the Nissen? I've seen
references on Pubmed to some Nissens causing sliding hiatal hernias,
but I'm not knowledgable enough to determine the likelihood of this.

2. Should I be pressuring my primary care doctor more for a referral
to an appropriate surgical consult or a GI consult?
From: Howard McCollister on 26 Sep 2005 23:11

"Richard Kaszeta" <rich(a)kaszeta.org> wrote in message
news:y6xk6h6hx47.fsf(a)pomme.me.umn.edu...
> This is one for Howard, if he's still reading here:
>
> In 2001, I had a Nissen Fundoplication done, which resulted in the
> near elimination of my acid reflux discomfort, although I still take
> 20mg Prilosec 1x/day, and rarely have any gastrointestinal discomfort
> unless I badly abuse my stomach (large, repeated heavy meals with high
> acid content), usually I'm fine.
>
> However, starting in June I started having *severe* stabbing shoulder
> pain, primarly in the left shoulder. After a series of X-rays, blood
> tests, and a CT scan, my doctors and the radiologist are of the
> opinion that the pain is referred pain from diaphragmatic irritation,
> but my primary care provider does not think that a consultation with a
> GI specialistic is warranted (since my last endoscopy two years ago
> was fine), nor is a consult with a surgeon appropriate, and instead
> has been treating the symptoms with painkillers (Vicodin). I'm hoping
> that a better solution than Vicodin can be found.
>
> Two questions:
>
> 1. Can this shoulder pain be caused by something wrong with my
> esophagus, stomach, or the results of the Nissen? I've seen
> references on Pubmed to some Nissens causing sliding hiatal hernias,
> but I'm not knowledgable enough to determine the likelihood of this.
>
> 2. Should I be pressuring my primary care doctor more for a referral
> to an appropriate surgical consult or a GI consult?

One of the possbile problems that can develop in patients with a
fundoplication is "slipping" of the wrap partially into the chest. This
appears to be most frequently caused by unrecognized shortening of the
esophagus due to scarring from chronic esophagitis. Then when the wrap is
done, there's too much tension on the stomach and wrap, which in turn wants
to pull the whole thing back into the chest, which in turn can cause the
diaphragmatic irritation you describe.

The most sensitive diagnostic test is an EGD, and that is certainly where
you need to start. The problem is that gastroenterologists frequently don't
understand what they're looking at when they are evaluating the integrity
and positioning of the wrap. They aren't surgeons and rarely understand the
nuances of EGD findings in these kind of situations. Upper GI contrast study
(xray) is a poor way to do this evaluation.

HMc




From: Richard Kaszeta on 27 Sep 2005 09:28
"Howard McCollister" <nospam(a)nospam.net> writes:
> One of the possbile problems that can develop in patients with a
> fundoplication is "slipping" of the wrap partially into the chest. This
> appears to be most frequently caused by unrecognized shortening of the
> esophagus due to scarring from chronic esophagitis. Then when the wrap is
> done, there's too much tension on the stomach and wrap, which in turn wants
> to pull the whole thing back into the chest, which in turn can cause the
> diaphragmatic irritation you describe.
>
> The most sensitive diagnostic test is an EGD, and that is certainly where
> you need to start. The problem is that gastroenterologists frequently don't
> understand what they're looking at when they are evaluating the integrity
> and positioning of the wrap. They aren't surgeons and rarely understand the
> nuances of EGD findings in these kind of situations. Upper GI contrast study
> (xray) is a poor way to do this evaluation.

Many thanks, I'll be sure to talk to the gastroenterologist about this
when I see him.

--
Richard W Kaszeta
rich(a)kaszeta.org
http://www.kaszeta.org/rich
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