But I Have Reflux…

When I first started this blog, I promised topics about gastroenterology and esophageal problems.  So let me talk about one today.  I consider this the most fundamental issue I see in my office on a regular basis: the difference between heartburn and reflux.  I have told many of my trainees this: “Patients are not allowed to complain of reflux.”  Usually they look at me funny, until I explain myself…

There are plenty of terms that reflux also goes by.  Acid reflux, hiatal hernia, esophagitis, GERD (which stands for “gastroesophageal reflux disease”).  Decades ago, these were terms that only medical professionals used. In years past people complained of heartburn, but now many of my patients complain of reflux.  What is the difference?

If you just want a simple answer, this is it:

Heartburn is a symptom, not a disease; GERD [reflux] is a disease, not a symptom.

If that makes sense to you, great!  You’ve achieved something that medical students, nurses, doctors, and researchers cannot seem to always grasp.  More often than not, this explanation does not sink in.

So to help explain, let me start with an analogy, headache.

Most people have had a headache.  A headache is a symptom, not a disease.  A headache can be caused by many things.  Most people with a headache that brings them to the doctor would start by saying something like, “I’m having headaches.”  This is what we call the “chief complaint.”  The doctor would take a history, do an exam, make a diagnosis (or come up with a few things that could be going on, the “differential diagnosis“), and probably recommend some treatment.  The doctor might tell the patient that he/she has a migraine.  Migraine is the diagnosis ostensibly causing the headache; it is a specific type of headache that has certain characteristic features.  It is a common cause of headache.  But ultimately, it is a diagnosis, based on a doctor’s assessment.

Is this starting to make sense yet?  Maybe, maybe not.  It might not if you might think that the terms headache and migraine are the same.  If that is the case, then let me do this quick exercise.  I will copy some of the paragraph above and substitute another diagnosis in place of a migraine:

Most people have had a headache.  A headache is a symptom, not a disease.  A headache can be caused by many things.  Most people with a headache that brings them to the doctor would start by saying something like, “I’m having headaches.”  This is what we call the “chief complaint.”  The doctor would take a history, do an exam, make a diagnosis (or come up with a few things that could be going on, the “differential diagnosis”), and probably recommend some treatment.  The doctor might tell the patient that he/she has a brain tumorBrain tumor is the diagnosis ostensibly causing the headache…

Does this make a little bit more sense now?  Something about the examination, maybe some additional tests, made the doctor consider or even diagnose a brain tumor, a specific disease that can cause a headache.

Not yet understanding?  OK, let me make a few changes to the prior exercise, and I’ll change the headache to hip pain.

Hip pain is a symptom, not a disease. Most people with hip pain that brings them to the doctor would start by saying something like, “I’m having hip pain.”  … The doctor would take a history, do an exam, make a diagnosis …, and probably recommend some treatment.  The doctor might tell the patient that he/she has arthritisArthritis is the diagnosis ostensibly causing the hip pain

In this instance, the doctor diagnosed the patient with arthritis as the cause of the hip pain. Like headache, hip pain could be something else.  Does everyone with hip pain actually have arthritis? NO.  Does everyone with arthritis (of the hip) have pain? NO.

I have used the examples of a migraine and arthritis for specific reasons.  Like GERD, these terms have “turned into” symptoms themselves.  Think about it…have you (or someone you know) ever complained about a migraine or about arthritis?  Maybe it was because, at some point in your life, a doctor told you that was the cause of your symptom, and you have used the term ever since.  Possibly, it wasn’t your doctor, maybe a friend, a relative, or nowadays an advertisement for a drug or a digital media source.  Potentially the source was right, potentially the source was partially or completely wrong.  But somehow the term has become “anchored” to the symptom.

Hopefully this has begun to make sense.  Now, what about heartburn and reflux?  Think back to what I said originally:

Heartburn is a symptom, not a disease; GERD [reflux] is a disease, not a symptom.

Heartburn is a symptom that many people have.  The most appropriate lay definition is a burning sensation behind the breastbone the seems to rise up toward the throat.  You might think of heartburn as something else, maybe a burning pain focused on the upper abdomen.  Maybe burning in the throat or queasiness centered around your bellybutton.  Maybe even chest pain.  All of these symptoms are distinct and have many different causes besides GERD.  When someone tells me that they have heartburn, I want to make sure I know exactly what they mean.

The most common cause of heartburn is GERD. But it is not the only cause!!

GERD is a disease.  Without getting into exquisite detail now, the lay definition for GERD is a syndrome in which the reflux (or backwards movement) of stomach contents into the esophagus causes symptoms, damage, or complications.

GERD might cause heartburn.  Heartburn is the most common symptom of GERD, but it is not the only symptom.

There are a number of other symptoms that GERD can cause, like regurgitation of food, pain in the chest, or cough. Just like arthritis, not everyone with GERD has heartburn.  And not everybody with regurgitation, chest pain, or cough has GERD as the cause.

So when that patient in my office tells me that they have reflux, I get down to the nitty-gritty and ask them what they mean.  Because the symptom they actually have, whether it is heartburn, chest pain, or something else, may not be GERD at all.

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About Ryan Madanick, MD

I am a gastroenterologist at the University of North Carolina School of Medicine, and the Vice-Chief for education in the Division of GI & Hepatology . I specialize in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD. I can be followed on Twitter: @RyanMadanickMD (he/him)
This entry was posted in Esophagus, gastroenterology, GERD, Heartburn and tagged , , , , , , . Bookmark the permalink.

One Response to But I Have Reflux…

  1. Pingback: Are we really training learners to manage diseases? | Gut Check Blog

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