What is the diagnosis and treatment plan for my ongoing gastrointestinal symptoms, including abdominal pain, LPR (Laryngopharyngeal Reflux) symptoms, and anal fissures, in the context of my existing HNPP (Hereditary Neuropathy with Liability to Pressure Palsies) and previously treated H. pylori infection?

Clinical Assessment and Diagnosis

You have multiple overlapping conditions: confirmed HNPP (Hereditary Neuropathy with Liability to Pressure Palsies) causing your left arm symptoms, successfully treated H. pylori infection, laryngopharyngeal reflux (LPR) requiring ongoing PPI therapy, and a likely anal fissure from constipation—not a single unifying diagnosis but rather concurrent conditions that require targeted management for each.

Your Neurological Symptoms (Left Arm, Neck, Shoulder)

Your left-sided arm twitching, numbness, neck stiffness, and radiating pain are explained by your confirmed HNPP diagnosis with documented nerve conduction velocity at half the normal rate 1. The key features that distinguish this from other causes:

• HNPP characteristically causes recurrent, positional nerve palsies that come and go, typically triggered by pressure or repetitive movements 1
• Your normal cervical spine MRI (only minimal C5-6 changes), normal brachial plexus MRI, and normal brain MRI effectively rule out structural causes like cervical radiculopathy, brachial plexopathy, or CNS pathology 1
• The left-sided predominance and intermittent nature fit HNPP's typical presentation 1

Management approach for HNPP:

• Avoid prolonged pressure on nerves (no leaning on elbows, crossing legs, or repetitive movements) 1
• Continue B12 1000 mcg daily since your level was deficient at 149 (normal >200) 1
• Physical therapy focused on nerve gliding exercises and posture correction 1
• The physiatrist was correct that treatment options are limited—HNPP management is primarily preventive and supportive 1

Your Gastrointestinal Issues

H. pylori Status and Testing

Your H. pylori has been successfully eradicated based on two negative breath tests performed correctly (off PPI for 2 weeks before testing, last test [DATE]) 2, 3. The quadruple therapy you completed ([DATE] to [DATE]) is the recommended first-line treatment with 14-day duration 2, 3.

Ongoing Abdominal Pain and LPR Symptoms

Your persistent mid-epigastric discomfort and LPR symptoms (sour taste, swallowing sensation) represent functional dyspepsia and laryngopharyngeal reflux that require continued acid suppression, not residual H. pylori infection 1.

Optimize your PPI therapy:

• Increase pantoprazole from 40 mg once daily to 40 mg twice daily (before breakfast and dinner) for better control of LPR symptoms 1, 4, 5
• LPR requires more aggressive acid suppression than typical GERD because even small amounts of acid reaching the larynx cause symptoms 1, 5, 6
• Take the medication 30-60 minutes before meals for optimal effect 7, 8
• Continue this regimen for at least 8-12 weeks before reassessing 1, 5

Critical lifestyle modifications for LPR:

• Elevate the head of your bed by 6-8 inches (not just pillows) 1, 5
• Avoid eating within 2-3 hours of lying down 1, 5
• Sleep in the left lateral position if possible 5
• Avoid trigger foods: coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks 1, 5
• Pursue weight loss if overweight—this has the strongest evidence for reducing reflux 1, 5

Regarding Your Upcoming Endoscopy ([DATE])

The endoscopy is appropriate given your persistent symptoms despite treatment, history of H. pylori, and need to rule out other pathology 1, 8. The endoscopy will:

• Assess for erosive esophagitis, Barrett's esophagus, or peptic ulcer disease 1
• Confirm successful H. pylori eradication via biopsy if needed 1, 3
• Rule out gastric malignancy (important given your age and symptom duration) 1, 8
• Evaluate for gastroparesis or other structural abnormalities 9

Important caveat: Symptomatic response to PPI does not exclude gastric malignancy, which is why endoscopy is warranted in your case 8.

Your Rectal Bleeding and Constipation

You have a classic anal fissure from constipation and straining, not gastrointestinal bleeding from upper GI pathology 1. The key distinguishing features:

• Bright red to brownish-red blood on the surface of stool and toilet paper (not mixed in) 1
• Associated with hard stools that "got stuck halfway" 1
• Pain with bowel movements (though you didn't explicitly mention this) 1
• Onset correlating with constipation and inadequate fiber/laxative use 1

Management of anal fissure and constipation:

• Continue RestoraLAX (polyethylene glycol) daily as you started 1
• Increase dietary fiber gradually to 25-30 grams daily 1
• Ensure adequate hydration (8 glasses of water daily) 1
• Consider adding a stool softener (docusate) if stools remain hard 1
• Warm sitz baths 2-3 times daily for 10-15 minutes 1
• Apply topical nitroglycerin 0.2% or diltiazem 2% ointment if fissure persists beyond 6 weeks 1

Your bland diet of potatoes, rice, and chicken is contributing to constipation—you need more fiber from vegetables, fruits, and whole grains 1.

Why Your Symptoms Overlap and Confuse the Picture

Several factors create diagnostic complexity in your case:

• Pain perception: When you have severe back or shoulder pain from HNPP, you may not notice abdominal discomfort—this is normal pain gating, not evidence that one condition causes the other 1
• PPI effects on symptoms: Restarting pantoprazole may have initially increased abdominal awareness, but this typically improves with continued use 1, 8
• Anxiety and symptom amplification: Your multiple ER visits for chest pain (with negative cardiac workup) suggest heightened symptom awareness, which can amplify both GI and neurological symptoms 1
• H. pylori and LPR connection: H. pylori can colonize laryngeal mucosa and may have contributed to your LPR symptoms, though eradication doesn't always resolve LPR immediately 6, 10

What You Don't Have

Based on your extensive workup, you do not have:

• Thoracic outlet syndrome (TOS)—your neurologist correctly noted this cannot be diagnosed based on your findings, and your normal brachial plexus MRI excludes structural compression 1
• Cervical radiculopathy—minimal C5-6 changes on MRI are insufficient to explain your symptoms 1
• Active H. pylori infection—two negative breath tests confirm eradication 2, 3
• Cardiac disease—multiple ER evaluations ruled out heart attack 1
• CNS pathology—normal brain MRI excludes stroke, MS, or tumor 1

Post-Endoscopy Management Plan

If endoscopy shows erosive esophagitis (Los Angeles grade B or higher):

• Continue pantoprazole 40 mg twice daily indefinitely 1, 8
• Cannot wean off PPI due to risk of recurrent erosions 1

If endoscopy is normal or shows only mild changes:

• Continue pantoprazole 40 mg twice daily for 8-12 weeks 1
• Then attempt to wean to lowest effective dose (possibly once daily or on-demand) 1
• Consider adding H2-receptor antagonist (famotidine 20 mg) at bedtime for breakthrough nighttime symptoms 1

If symptoms persist despite optimized PPI therapy after endoscopy:

• Consider 96-hour wireless pH monitoring off PPI to objectively document acid exposure 1, 5
• Evaluate for functional dyspepsia and consider tricyclic antidepressant (amitriptyline 10 mg at bedtime, titrated to 30-50 mg) as a neuromodulator 1
• Refer to gastroenterology for specialized management including possible gut-brain behavioral therapies 1

Critical Pitfalls to Avoid

• Do not stop PPI abruptly—this causes rebound acid hypersecretion and worsening symptoms 1
• Do not assume all your symptoms are from one condition—you have multiple concurrent diagnoses requiring separate management 1
• Do not repeat H. pylori testing—you've had two negative tests with proper technique; further testing is unnecessary 2, 3
• Do not use opioids for any of your pain—they worsen gastroparesis, constipation, and functional GI symptoms 1, 9
• Do not pursue surgery for GERD/LPR until you've exhausted medical management and had comprehensive esophageal physiologic testing 1