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?
Case Studies
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2
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?
Students must review the case study and answer all questions with a scholarly response using APA and include 2 scholarly references.
Answers must be scholarly and be 3-4 sentences in length with rationale and explanation. “No Straight forward / Simple answer will be accepted”.
All answers to case studies must have the references cited “in the text” for each answer and a minimum of 2 Scholarly References (Journals, books) (No websites) per case Study
- The patient is instructed to avoid tobacco and caffeine because both substances can contribute to increased acid production and relaxation of the lower esophageal sphincter (LES). Tobacco smoke irritates the esophageal lining and can weaken the LES, allowing stomach acid to reflux into the esophagus. Caffeine, found in coffee, tea, and certain sodas, can also relax the LES and stimulate acid secretion, exacerbating symptoms of gastroesophageal reflux disease (GERD).
- The physician recommended 6 weeks of medical management to allow sufficient time for the prescribed medication, esomeprazole (Nexium), to reduce gastric acid production and heal the esophagitis caused by severe reflux. Six weeks is a common timeframe for assessing the response to proton pump inhibitor (PPI) therapy, which aims to control symptoms and promote healing of the esophageal mucosa. If there is inadequate improvement after this period, further interventions such as surgery may be considered.
- Antacid medications, such as proton pump inhibitors (PPIs) like esomeprazole, work in patients with gastroesophageal reflux by reducing the production of stomach acid. PPIs inhibit the proton pumps in the stomach lining responsible for acid secretion. By decreasing acid levels, PPIs help alleviate the symptoms of heartburn and regurgitation and allow the esophageal mucosa to heal. They provide more sustained acid suppression compared to other antacids and are effective in managing GERD.
- If the patient decided not to take the prescribed medication and requested an alternative medicine approach, it would be important to have a thorough discussion about the risks and benefits of alternative treatments. It is crucial to explain that alternative remedies have limited scientific evidence supporting their efficacy in managing GERD. However, certain lifestyle modifications may be recommended, such as maintaining a healthy weight, avoiding large meals before bedtime, elevating the head of the bed, and identifying and avoiding trigger foods. It is important to emphasize that medical management, including PPIs, has been proven effective in controlling symptoms and preventing complications of GERD, and alternative approaches may not provide the same level of relief.