Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Esophageal Reflux
Case Studies
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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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?
- The patient was instructed to avoid tobacco and caffeine because both substances can exacerbate the symptoms of gastroesophageal reflux disease (GERD). Tobacco can relax the lower esophageal sphincter (LES), which is the muscular ring that separates the esophagus from the stomach. When the LES relaxes, it allows stomach acid to flow back into the esophagus, leading to heartburn and other symptoms of GERD. Caffeine, found in coffee, tea, and many other beverages, can also relax the LES and stimulate the production of stomach acid, making reflux more likely and intensifying the symptoms.
- The physician recommended 6 weeks of medical management before considering surgical intervention because it is a standard approach in the treatment of GERD. Medical management typically involves the use of medications, such as proton pump inhibitors (PPIs) like esomeprazole (Nexium), to reduce stomach acid production and alleviate the symptoms of GERD. This approach is often tried first to see if it can control the patient’s symptoms without the need for surgery. It allows time to assess the patient’s response to medication and to make necessary lifestyle modifications.
- Antacid medications, such as proton pump inhibitors (PPIs) like esomeprazole (Nexium), work in patients with gastroesophageal reflux by reducing the production of stomach acid. PPIs block the proton pump, which is responsible for acid production in the stomach. By decreasing stomach acid levels, these medications help to alleviate the symptoms of GERD, including heartburn, regurgitation, and esophagitis. They provide relief by reducing the acidity of the gastric contents that can reflux into the esophagus, thus minimizing irritation and damage to the esophageal lining.
- If a patient decided not to take the prescribed medication and asked for an alternative approach, several options could be considered, but it’s crucial for the patient to discuss these alternatives with their healthcare provider. Here are some alternative approaches that might be considered:
a. Lifestyle modifications: Emphasize the importance of lifestyle changes, such as maintaining a healthy weight, avoiding trigger foods (e.g., spicy and acidic foods), eating smaller meals, not lying down immediately after eating, and elevating the head of the bed while sleeping.
b. Dietary changes: Suggest dietary changes that can help reduce symptoms, such as avoiding alcohol, caffeine, fatty foods, and citrus fruits. Encourage a diet rich in fruits, vegetables, and whole grains.
c. Over-the-counter (OTC) antacids: Over-the-counter antacid medications, like calcium carbonate (Tums) or aluminum hydroxide/magnesium hydroxide (Maalox), can provide temporary relief from heartburn and acid reflux symptoms.
d. Herbal remedies: Some people explore herbal remedies like ginger, licorice, or chamomile, which are believed to have soothing effects on the digestive system. However, the efficacy of these remedies varies from person to person, and they should be used with caution.
e. Consultation with a specialist: If the patient remains resistant to medication and lifestyle changes, it may be wise to consult with a gastroenterologist or an alternative medicine practitioner who specializes in GERD to explore additional alternative therapies.
Ultimately, the choice of treatment should be made in consultation with a healthcare provider who can provide guidance based on the patient’s individual circumstances and preferences.