Barrett's + hiatal hernia treatment plan?
Hi everyone, I'm a 28-yr old American living in Japan for the past several years and I'd like to ask for advice and feedback on my condition and current treatment regimen. I'm particularly curious about what is standard practice for treating patients in the US like myself.
In May of this year I experienced a few episodes of severe chest pain in the middle of the night landing me in the ER. Subsequent endoscopy and tissue biopsy led to a diagnosis of a 2cm esophageal ulcer and Barrett's esophagus without dysplasia.
In September had another endoscopy which yielded an additional diagnosis of hiatal hernia. The physician characterized my hernia as simply an enlarging of the opening in the diaphragm that the esophagus passes through and not a sliding or paraesophageal hiatal hernia. I have uploaded two endoscopy photos here where BE and hernia are visible:
Above the LES: http://fgnfierjn.freewebspace.com/1.jpg
Below the LES via retroflexing the endoscope: http://fgnfierjn.freewebspace.com/2.jpg
Before those May episodes I was symptomless so it's unclear as to how long I had undiagnosed GERD that led to the BE and ulcer. In September I sought out a follow-up endoscopy because nighttime GERD symptoms started to emerge regularly (pain at night or upon waking). At that time the physician added an H2 blocker to the PPI I had been prescribed in May since she believed H2 blockers are better at controlling nighttime GERD. My current regimen is a PPI before dinner and an H2 blocker at night before bed. I have also made lifestyle adjustments (sleep with torso elevated, sleep on left side, reduce stress, food/drink, etc). I haven't experienced any pain or other symptoms for a few months. I plan on continuing the drug regimen indefinitely and having an endoscopy and biopsy once per year from now on.
Nonetheless, I feel uneasy because of the seriousness of BE and the lack of clarity about my hiatal hernia. Also because I developed BE and even an ulcer without symptoms for months, without verification by endoscopy I can't know if the condition is truly "under control."
My questions are as follows:
1. Is my current drug regimen (combination of PPI before dinner and H2 blocker before bed) standard practice in the US? If not, what is?
2. Can or should drug treatment be continued indefinitely? My one physician friend in the US believes BE is too serious to not treat at least with a PPI for the rest of my life. Should I at least try and phase out the H2 blocker?
3. Am I at a heightened risk level of developing dysplasia due to my hiatal hernia? Do I need to seek out additional treatment for the hernia itself or because of my combination BE-hiatal hernia? I have read about Nissen fundoplication, but due to the level of invasiveness and risk of complications it seems like a last resort.
4. In general, what is standard practice in the US for treating BE-hiatal hernia patients like myself, particularly those who develop these conditions at a relatively young age (again I'm 28)? If there is anything I'm missing or treatment I need to seek out, I would like to know.
Apologies for the lengthy post, but I would be extremely thankful to receive any advice or ideas. Many thanks to you all.