A 45-year-old woman complained of heartburn and frequent regurgitation of “sour” material into
her mouth. Often while sleeping, she would be awakened by a severe cough. The results of her
physical examination were negative.
Studies Results
Routine laboratory studies Negative
Barium swallow (BS), p. 941 Hiatal hernia
Esophageal function studies (EFS), p. 624
Lower esophageal sphincter (LES)
pressure
4 mm Hg (normal: 10–20 mm Hg)
Acid reflux Positive in all positions (normal: negative)
Acid clearing Cleared to pH 5 after 20 swallows (normal:
<10 swallows)
Swallowing waves Normal amplitude and normal progression
Bernstein test Positive for pain (normal: negative)
Esophagogastroduodenoscopy (EGD), p. 547 Reddened, hyperemic, esophageal mucosa
Gastric scan, p. 743 Reflux of gastric contents to the lungs
Swallowing function, p. 1014 No aspiration during swallowing
Diagnostic Analysis
The barium swallow indicated a hiatal hernia. Although many patients with a hiatal hernia have
no reflux, this patient’s symptoms of reflux necessitated esophageal function studies. She was
found to have a hypotensive LES pressure along with severe acid reflux into her esophagus. The
abnormal acid clearing and the positive Bernstein test result indicated esophagitis caused by
severe reflux. The esophagitis was directly visualized during esophagoscopy. Her coughing and
shortness of breath at night were caused by aspiration of gastric contents while sleeping. This
was demonstrated by the gastric nuclear scan. When awake, she did not aspirate, as evident
during the swallowing function study. The patient was prescribed esomeprazole (Nexium). She
was told to avoid the use of tobacco and caffeine. Her diet was limited to small, frequent, bland
feedings. She was instructed to sleep with the head of her bed elevated at night. Because she had
only minimal relief of her symptoms after 6 weeks of medical management, she underwent a
laparoscopic surgical antireflux procedure. She had no further symptoms.
Critical Thinking Questions
1. Why would the patient be instructed to avoid tobacco and caffeine?
2. Why did the physician recommend 6 weeks of medical management?
3. How do antacid medication work in patients with gastroesophageal reflux?
4. What would you approach the situation, if your patient decided not to take the medication
and asked you for an alternative medicine approach?
A 45-year-old woman presented with heartburn, frequent regurgitation of “sour” material into her mouth, and a severe cough. The physical examination was negative, but the barium swallow revealed a hiatal hernia. Esophageal function studies were performed and showed that the patient had severe acid reflux into her esophagus, along with a hypotensive lower esophageal sphincter (LES) pressure. The positive Bernstein test result indicated that the patient had esophagitis caused by severe reflux. The esophagitis was directly visualized during esophagoscopy, and the gastric nuclear scan demonstrated that the patient was aspirating gastric contents while sleeping. The patient was prescribed esomeprazole, told to avoid tobacco and caffeine, and to sleep with the head of her bed elevated at night. After 6 weeks of medical management, the patient underwent a laparoscopic surgical antireflux procedure, which resolved her symptoms.
Tobacco and caffeine are known to increase gastric acid secretion and relax the LES, which can exacerbate symptoms of gastroesophageal reflux. Therefore, the patient was instructed to avoid tobacco and caffeine to improve her symptoms.
The physician recommended 6 weeks of medical management because it typically takes several weeks for proton pump inhibitors like esomeprazole to achieve maximal effectiveness in controlling symptoms of gastroesophageal reflux.
Antacid medication neutralizes the acid that refluxes into the esophagus and can provide temporary relief of symptoms. However, they do not reduce acid production or prevent further reflux. Proton pump inhibitors like esomeprazole are more effective at controlling symptoms because they reduce acid production by blocking the proton pumps in the stomach.
If a patient decides not to take medication and requests an alternative approach, the physician could recommend lifestyle modifications such as avoiding trigger foods, losing weight, and elevating the head of the bed. The physician could also recommend alternative therapies such as herbal remedies or acupuncture, but caution the patient that these treatments have not been thoroughly studied for their effectiveness in treating gastroesophageal reflux. Additionally, the physician should monitor the patient closely to ensure that their symptoms do not worsen and that they do not develop complications such as esophagitis or Barrett’s esophagus.