# WHEN IS IT JUST A BURP



## eric (Jul 8, 1999)

with permissionWHEN IS IT JUST A BURP ï¿½ AND WHEN IS IT REFLUX?By Nicholas J. Shaheen, MDAssistant Professor of Medicine, School of MedicineUniversity of North Carolina at Chapel HillMuch of the public's confusion about gastroesophageal reflux disease (GERD) stemsfrom the difficulty recognizing the disease. Unlike a broken leg or a bloody nose, GERDmay be a subtle, yet destructive disease. Since up to 40% of adults experience at leastsome GERD symptoms, questions involving the condition are important. What is GERD,and when and why should you be concerned about it?What is GERDGERD is an upward displacement of stomach fluids into the esophagus, which leads tocertain symptoms or damage to the esophagus. The most common symptom of refluxdisease is heartburn. This is the familiar substernal chest burning that often radiatesfrom the lower tip of the breastbone upwards into the lower and then upper chest. Thissymptom may be accompanied by burping, excessive salivation filling the mouth withwater (known as waterbrash), and dysphagia (difficulty swallowing food). Thesesymptoms may be positional and worse when lying down. They may also be worse wheneating or drinking, especially certain items -- such as alcohol, peppermint, fatty foods,and acidic foods (such as orange juice).While the symptoms described above have long been associated with reflux disease,there is now a growing concern about other symptoms that can be caused by reflux.These symptoms are known as the extra-esophageal symptoms of reflux and includemanifestations such as asthma, laryngitis, chronic cough, halitosis (bad breath), andeven sleep disorders. These symptoms are much more commonly caused by GERDthan had been previously recognized. For instance, up to 30% of chronic cough patientshave GERD as a reason for their cough. Furthermore, up to half of those with an extraesophagealmanifestation of reflux will not have heartburn. This means their physicianswill not have a helpful clue that their symptom is caused by GERD. Extra-esophagealreflux may be more than a nuisance -- studies have shown that GERD is a strong riskfactor for laryngeal cancer, as well.When should a person with heartburn be concerned about GERD?Unfortunately, there is no simple answer to this question. It turns out that severity ofsymptoms is poorly predictive of severity of GERD -- some subjects with very highamounts of acid coming up into the chest may have only trivial symptoms of reflux,whereas others with severe symptoms may have relatively normal acid exposures. Onthe other hand, frequency of GERD symptoms is a relatively strong indicator of GERDseverity.What does this mean? If you are a person who gets severe heartburn once every othermonth after a night of beer and pizza, a few TUMS and a little less food and drink nexttime may be all that is necessary. On the other hand, if you are experiencing symptomsweekly or more often on a normal diet, even if the symptoms are not severe, discussionwith your doctor is advisable.How do we treat GERD?Elevating the head of the bed with bricks, avoiding late night and/or large meals,cessation of smoking and drinking alcohol, and avoidance of the foods mentioned aboveare some of the measures that we commonly suggest. For those in whom thesemeasures fail to give relief, drug therapy is recommended.Although antacids are fine for infrequent or mild symptoms, they are not a good strategyfor frequent or severe symptoms. Too many people we see in our clinic are goingthrough a bottle of TUMS every 2-3 days before they discuss the problem with theirdoctor. Some of these patients may do fine with an H2 receptor antagonist, such asZantac, Tagamet, Pepcid, or Axid. Over-the-counter varieties of these medications are athalf the strength of the prescription medications, so failure of over-the-countermedications does not necessarily mean you might not respond well to prescriptiondoses.Your doctor may prescribe a proton pump inhibitor. This class of medications includesPrilosec, Prevacid, Aciphex, Protonix, or Nexium. Proton pump inhibitors are the mostpotent acid suppressive drugs currently available. Although doctors were initiallyconcerned that long-term usage of these agents might be harmful to patients, studiesnow indicate these drugs are safe even when taken continuously for years. Thisexcellent safety record has led the Food and Drug Administration (FDA) to permitmanufacturers to market Prilosec to go over-the-counter.Some patients with relatively severe GERD might opt to undergo a surgical anti-refluxprocedure. This surgery can now be done laparoscopically, which is a minimally invasivetechnique. This option might be particularly attractive for the patient who is unable to getgood control of his or her symptoms even with maximum medications, or the patient whodislikes or forgets to take his/her medicine.GERD can cause problems beyond discomfortLong-term exposure of the esophagus to acid can cause a narrowing of the esophagus,called stricture formation. This problem is usually amenable to endoscopic therapy, inwhich balloons or dilators are used to stretch the esophagus to a more normal diameter.Erosive esophagitis is a condition where the esophageal lining is eaten away by thegastric contents. The inflamed area can bleed or cause chest pain.Perhaps the most devastating complication of GERD is the development of esophagealcancer. Patients with frequent severe GERD are 16 times more likely to get esophagealcancer than people who do not experience GERD. The cancer is thought to occurbecause the normal lining of the esophagus transforms or changes into a pre-malignantstate known as Barrett's esophagus. Over time, a small portion of people with Barrett'swill progress on to cancer.Use of upper endoscopy to assess the condition of their esophagusCertain symptoms, known as alarm symptoms, are known to be associated with severeconditions of the esophagus and deserve immediate investigation. These symptomsinclude dysphagia, odynophagia (pain with swallowing), anemia, throwing up or passingblood in the stools, and weight loss. Blood passed from the esophagus into the stool willoften appear jet black, a condition which is known as melena. It is less clear is when thesubject with GERD -- but no alarm symptoms -- needs endoscopy. The AmericanCollege of Gastroenterology suggests that anyone with long-term symptoms undergo asingle screening upper endoscopy. The primary goal of this examination is to look forBarrett's esophagus or early adenocarcinoma. If the patient is found to have Barrett'sesophagus, most doctors will recommend repeat endoscopies to monitor the Barrett'sand make sure it does not turn into cancer. Upper endoscopy may be especially usefulin patients who are older, Caucasian, and/or male, since all of these characteristics areknown as risk factors for esophageal cancer.New endoscopic techniquesNew endoscopic techniques have been developed to treat GERD without medications orsurgery. For example, endoscopic sewing devices "sew tight" the lower esophagus,allowing less acid to come up into the chest. Another example is the Stretta device,which uses heat to thicken the lower esophagus, thereby decreasing the amount of fluidthat is able to get up into the chest. Third, Enteryx is an injectable polymer that can beendoscopically placed at the lower end of the esophagus to thicken it, decreasing theamount of gastric contents that can reflux. Finally, the Plicator is similar to a giantstapler, designed to tighten the bottom of the esophagus with one big pacman-like bite,leaving a stitch that goes all the way through the wall of the stomach.Experience with all of these procedures is still rather preliminary, and it remains to beseen whether any of them will provide lasting relief of GERD symptoms. Theseprocedures do hold the promise, however, that one day GERD symptoms may beaddressed by the gastroenterologist without need of medications or surgeries.If you are confused about how much to be concerned about your GERD symptoms, youhave it right -- doctors are not always entirely clear when we need to worry about themeither. By following the simple suggestions above, you may be able to rid yourself ofthese bothersome symptoms with over-the-counter remedies. But, if that does notprovide the relief you need, do yourself a favor and talk to your doctor. http://www.med.unc.edu/wrkunits/2depts/med...just_a_burp.pdf


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