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Forum Name: Gastroenterology Topics

Question: Gnawing before and after eating, pressure in throat


 Berrycat - Tue Jun 29, 2010 2:20 pm

I have had off and on stomach problems for years and was diagnosed with a small hiatal hernia 5 years ago. Four months ago it got worse with an uncomfortable and sometimes painful gnawing in my stomach before and after eating (sometimes worse after eating). Dr instructed me to take Prilosec twice a day for a month and that took care of it. A few months later it came back and was worse, so different Dr (other doctor went to another clinic) prescribed the same thing with a Zantac (300 mg). That didn't help, so she prescribed Kapidex (pharmacy gave me Dexilant). At first it seemed to do the trick but it comes and goes. I'm about two weeks into the treatment and I am still having problems, along with what feels like a "bubble" and pressure in my throat. I never get the burning sensation of heartburn. I have found that taking a Zantac does help with the throat issue and that's when I feel the best. I'm trying to watch my diet, not having caffeine, chocolate, and high-fat foods, and feel best when I have a very bland diet with rice, applesauce, turkey, etc. but if I stray from that it all comes back. Am I not giving the medicine a chance to work? I was given a blood test for the bacteria but it came back negative. She did say to come back for another appt at the end of the 30 days if it doesn't work. Should I insist on going to a gastro Dr? My sister says the only thing that helped her was carafate, which I'm wondering if I should ask for that.
Advice? Thanks.
 Dr.M.Aroon kamath - Fri Jul 02, 2010 2:19 am

User avatar Hi,
You seem to have features of Gasto Esophgeal Reflux Disease (GERD).You had been noted to have a small hiatus hernia as well.

Protocols for the managements of patients with GERD vary. In order to make it more comprehensible for you, i will underline one protocol recommended by many.

Initial endoscopy is deferred unless a patient has
- evidence of bleeding,
- weight loss, or
- dysphagia.
Then, the patients are started on a 4–8-week trial course of a first generation proton pump inhibitor(PPI) to be taken strictly in the morning 30 min to 1 h before breakfast. Failure to respond at this point leads to
- checks on patient compliance and
- checks on the patients' adherence to the timing of the dose.

If patient compliance and the correct timing of the PPI dose are satisfactory and yet symptoms persist, switching over to a second-generation PPI is considered.[one variation is a twice-daily dosing (before breakfast and dinner) of the original PPI]. It is important to control nighttime acid reflux. Taking a H2 blocker before bedtime has been shown to be help by some.

If these measures fail, then further investigations are considered to exclude problems besides GERD ( hiatal hernias, motility disorders,refractory peptic ulcer disease or, less likely, gastric cancer, and can identify 'acid-resistant' esophagitis etc), which may be causing or aggravating the symptoms.

Needing more aggressive treatment does not mean the only option for these patients is surgery. In fact, those who have the best outcomes from anti-reflux surgery are those who previously responded to medications. The refractory patients don't typically respond as well to anti-reflux surgery. This, however, doesn't mean surgery, such as fundoplication, wouldn't be an option.

Tests which may be useful are:
- Upper endoscopy
- Ambulatory esophageal PH monitoring (while on PPIs),&
- Esophageal Manometry.
(Gastric pH monitoring ideally should be reserved for cases of suspected PPI resistance).

Newer techniques that may be useful include
- impedance-pH monitoring, which is very sensitive in detecting persistent vary weak acidic reflux,&
- bilirubin monitoring, which detects increased esophageal exposure to bile.

In your instance, your PPI dosage and timing should be regularized under supervision, as the first step. If you still continue to be symptomatic despite these measures, as discussed above, you will need further investigations.
Best wishes!
 Berrycat - Sun Jul 11, 2010 1:22 pm

Dr,
Thanks so much for your thoughtful reply; it really helped. I'm still having problems with varied symptoms so will be seeing the doctor again in a few days.
 Dr.M.Aroon kamath - Sun Jul 11, 2010 9:15 pm

User avatar Hi Berrycat,
Thank you for the update.I sincerely hope that you get well soon. Good luck!

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