Posted: August 7th, 2023

Esophageal Reflux: A Diagnostic and Therapeutic Case Study

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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?

Esophageal Reflux: A Diagnostic and Therapeutic Case Study

Introduction

This case study focuses on a 45-year-old woman who presented with heartburn and frequent regurgitation of “sour” material into her mouth. Additionally, she experienced severe coughing episodes during sleep. To arrive at a precise diagnosis and develop an appropriate treatment plan, several diagnostic tests were conducted, including routine laboratory studies, barium swallow (BS), esophageal function studies (EFS), Bernstein test, esophagogastroduodenoscopy (EGD), gastric scan, and swallowing function study.

Diagnostic Results and Analysis

The routine laboratory studies yielded negative results, suggesting no significant abnormalities in the patient’s blood chemistry. However, the barium swallow revealed the presence of a hiatal hernia, which is a protrusion of the stomach through the diaphragm into the chest cavity. While hiatal hernias do not always cause reflux, this patient’s symptoms warranted further investigation through esophageal function studies.

The EFS demonstrated a hypotensive lower esophageal sphincter (LES) pressure, measuring only 4 mm Hg (normal range: 10–20 mm Hg). Concurrently, acid reflux was found to be positive in all positions, indicating the presence of gastroesophageal reflux disease (GERD). The abnormal acid clearing observed, with the pH level returning to 5 after 20 swallows (normal: <10 swallows), further confirmed esophagitis due to severe reflux. Direct visualization through esophagoscopy revealed reddened and hyperemic esophageal mucosa, confirming the presence of esophagitis. Moreover, the patient’s coughing and breathlessness during sleep were attributed to gastric contents aspiration, as evidenced by the gastric nuclear scan. However, the swallowing function study showed no aspiration while awake.

Treatment Approach

Based on the diagnostic findings, the patient was prescribed esomeprazole (Nexium), a proton pump inhibitor (PPI) that reduces gastric acid production, providing relief from GERD symptoms. To support the medical management, the patient was advised to abstain from tobacco and caffeine consumption, as both substances can exacerbate GERD symptoms by relaxing the LES and increasing acid production in the stomach.

Nonetheless, despite adhering to the prescribed medical management for six weeks, the patient reported only minimal symptom relief. Consequently, a laparoscopic surgical antireflux procedure was recommended, which led to complete resolution of her symptoms.

Critical Thinking Questions

Avoiding tobacco and caffeine is essential for patients with GERD due to their impact on the lower esophageal sphincter (LES). Both substances can weaken the LES, leading to an increased risk of reflux and exacerbation of symptoms.

The physician recommended a 6-week medical management period to evaluate the effectiveness of the prescribed medication (esomeprazole) and lifestyle modifications. This duration allows sufficient time to gauge the patient’s response to the treatment and determine if further interventions are necessary.

Antacid medications work by neutralizing stomach acid, providing temporary relief from heartburn and acid reflux symptoms. However, they do not address the underlying cause of GERD, which is often related to LES dysfunction and excessive acid production.

If a patient declines conventional medication and seeks an alternative approach, it is crucial to engage in open communication and explore their concerns and preferences. As an expert, I would discuss evidence-based alternative therapies, such as dietary and lifestyle modifications, natural supplements with potential reflux-reducing properties, and the importance of regular follow-up to monitor their condition. It is essential to inform the patient about the potential risks and benefits of alternative approaches while emphasizing the significance of evidence-based practices.

References:

Pagana, K. D., & Pagana, T. J. (2018). Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition. Elsevier Inc.

Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. American Journal of Gastroenterology, 108(3), 308-328. doi:10.1038/ajg.2012.444

Triadafilopoulos, G. (2016). Esophageal Motility Disorders. Gastroenterology Clinics of North America, 45(2), 235-249. doi:10.1016/j.gtc.2016.01.003

Fass, R., Gasiorowska, A., & Naliboff, B. (2017). The Esophageal Impedance-pH Reflux Pattern Associates With the Efficacy of PPI Therapy in Patients With Heartburn. Gastroenterology, 153(3), 686-693.e1. doi:10.1053/j.gastro.2017.05.037