patient with ongoing reflux symptoms with, with, with, with evaluation and then how to, how to test them and how to interpret the tests. And I know we have subsequent lectures on PPIs as well as maybe non-medical and non, and even surgical approaches to the treatment of, of reflux, but maybe a few words on what do you do with a patient who has symptoms, but the pH test is negative and maybe there is some correlation of symptoms with, with the amount of physiologic reflux they are having. So quote unquote, either hypersensitive esophagus, or maybe even functional heartburn. What do you offer these patients for treatment? And that is the reflux hypersensitivity. So there is normal total acid exposure and then plus positive symptom association. So that is a reflux hypersensitivity. And then there is a study by Speckler where they showed that about 70% respond to fundoplication and about 30% respond to PPI plus antidepressants and baclofen therapy or so. So what I do initially, because a fundoplication is a surgical procedure, what I do is offer them the antidepressant therapy, the pain modulators or so, and which seemed to help a lot of patients. And if not, and if you definitely see a symptom association, then to proceed with fundoplication. However, I have to tell you though, in practice that not many patients would want to go for fundoplication because of the possible aftereffects. The main thing is it is reassuring for them to know that there is no true acid damage going on in the esophagus. So the reassurance seems to calm them down to some extent, as well as the antidepressant therapy along with the PPI still. There is a question in the chat box which says, if you have a borderline Demeester score, and I know you talked about pH less than 4, more than 6, you talked about reflux events less than 40, more than 80, they are talking about a borderline Demeester score. Should we consider significant acid reflux as a diagnosis in those patients? And how would you interpret that? I think that's the theme of the question. So you would have two, right? So Demeester score is normal is less than 14.72, more than 14.72 is considered as abnormal. So if you have a borderline Demeester score, and then you are looking at the total acid exposure time. So if you have a total acid exposure time of more than 6% with the borderline Demeester score, so that is diagnostic of reflux. If you have a borderline Demeester score, like say about 15 or so, and then the total acid exposure time is less than 4% of the 24 hours, then it would be a negative test. OK. I think so that's a good approach. So you're not just thinking of one number, but you're trying to integrate multiple points in the report. So you're looking at acid exposure time, you're looking at total number of reflux events, and the Demeester score. So I think that's great. Second question. What is your preferred neuromodulator for a hypersensitive esophagus? I think this is in follow-up to the discussion we just had. So the preferred neuromodulator, so Elavil at bedtime or Trazodone. OK. And do you typically start at a low dose? We start at a very low doses. The antidepressant doses for Elavil is 50 to 100 milligrams a day. But for this, we typically start with a 10 milligram dose or a 25 milligram dose or so, and then slowly go up from there. We have to be cautious in older patients, over 70 or so, and in men, because it can precipitate urinary retention if they have prostate hypertrophy. That is something to know. OK, great.

reflux symptoms

hypersensitive esophagus

functional heartburn

treatment options

test interpretation