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r/AskDoctorSmeeee•
08b

Possible causes of excessive burping and the need for endoscopy - preparing for appointment with gastroenterologist

I'm trying to prepare questions for an upcoming appointment with a gastroenterologist. I'm skeptical that an endoscopy is the right next step and want to be prepared to discuss with him in detail.

For a year or two I've had excessive burping and regular mild heartburn. It slowly got worse until I realized how bad it was. I also tend to feel a lot of pressure in my stomach/chest after eating larger meals - burping sometimes helps (weirdly enough, "deep" burps seem to help more). When that occurs, it takes 1-2 hours to resolve. I took Omeprazole (20mg) with significant improvement, but couldn't stop taking it without the symptoms returning. My PCP recommended I take it for a few months, and then stop to see if the symptoms resolve. That didn't go well (terrible heartburn when not taking it), even though I went for about five days without it.

Recently, he recommended trying 40mg, and gave me a referral for an endoscopy. In total, I've taken 20mg for about 8 months, and tried 40mg for a few days. 40mg seems to be a minor improvement over 20mg. While taking either dose, my symptoms are dramatically reduced but not completely resolved. I've tried some diet adjustments (no coffee, not eating right before bed, etc) all with minor improvement but nothing huge. I'm hesitant to stay on PPIs, as I'm not convinced there won't be long term side effects.

From my research, the typical causes would be GERD and a hiatal hernia. An endoscopy seemed to be the proper test for ruling out a number of possibilities. From what I read, a chest x-ray is a better method to confirm a hiatal hernia (which seems to be treated with continued PPIs). Is this a better first step?

What other tests should be considered? Is an endoscopy warranted as a follow-up to these symptoms and my reaction to PPIs? Any other causes that I should research? Should other medications be tried first? When I called the office, they seemed to jump to an endoscopy quickly (wanted to schedule without a separate consult), so I'd like to make sure that is the right direction (the cost and need for sedation makes me want to consider other options first if they make sense). Any pointers, questions, or directions for further research prior to the appointment would help.

Posted Apr 22, 2015, 5:04 AM UTC

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SmeeeeEmergency Physician (ER Doc)•

I wouldn't say they "jumped to an endoscopy" - you had a trial of a PPI with okay, but not great results. Chest x-ray isn't sensitive enough to diagnose a hiatal hernia. Adding fluoroscopy and barium could help, but now you're dealing with radiation. Endoscopy has its risk too - the sedation involved as well as the very low likelihood of a procedural complication. But they are exceedingly common, and can be used to diagnose a variety of things, including GERD, gastritis, hiatal hernia, ulcers, h. pylori, barrett's esophagus, or any other multitude of causes.

So overall, the most sensitive and specific test would be endoscopy.

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08bOP•

Thanks for the reply. I think I'm likely focused on a less than complete list of possible causes in my head. Gives me a few things to discuss further at my appointment.

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honeybadgerrrrPA- Student•

I think Dr. Smeeee answered your question, but out of curiousity, how did you stop your PPI? If you do a trial, and abruptly stop, you may get a 'rebound' of symptoms. My physician professor said this commonly occurs because people are told to stop and not told to taper. Maybe ask your physician if this is a reasonable last ditch effort?

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08bOP•

Good point. I've heard of rebound symptoms, but I didn't taper as I was taking 20mg at the time. I thought rebound symptoms would resolve after a week or so (I waited about a week before resuming) but I haven't seen a lot data on how to taper. I'll discuss to see if that makes sense to try.

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