Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests
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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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?
Sample Solution
Critical Thinking Questions
1. Why would the patient be instructed to avoid tobacco and caffeine?
Tobacco and caffeine can relax the lower esophageal sphincter (LES), which can make acid reflux worse.
The LES is a muscle that acts as a valve between the esophagus and the stomach. When the LES is working properly, it prevents stomach acid from backing up into the esophagus. However, when the LES is relaxed, stomach acid can leak back into the esophagus, causing heartburn and other symptoms of acid reflux.
Tobacco and caffeine can both relax the LES. Tobacco contains nicotine, which is a stimulant that can relax muscles throughout the body. Caffeine is a stimulant that can also relax the LES.
Full Answer Section
. Why did the physician recommend 6 weeks of medical management? Medical management for acid reflux typically includes proton pump inhibitors (PPIs), such as esomeprazole (Nexium). PPIs work by blocking the production of stomach acid. PPIs can be very effective in relieving acid reflux symptoms. However, they can take some time to work. It is typically recommended that patients take PPIs for at least 6 weeks before determining whether the medication is effective. In addition to PPIs, there are a number of lifestyle changes that can also help to relieve acid reflux symptoms. These include:- Avoiding tobacco and caffeine
- Eating small, frequent meals
- Avoiding foods that trigger acid reflux symptoms, such as spicy foods, fatty foods, and citrus fruits
- Elevating the head of the bed at night
- Heartburn
- Regurgitation of sour material into the mouth
- Coughing, especially at night
- Wheezing
- Hoarseness
- Difficulty swallowing
- Chest pain
- Hiatal hernia: A hiatal hernia is a condition in which the upper part of the stomach pushes through the diaphragm and into the chest.
- Weak lower esophageal sphincter (LES): The LES is a muscle that acts as a valve between the esophagus and the stomach. When the LES is weak, stomach acid can leak back into the esophagus.
- Delayed gastric emptying: Delayed gastric emptying is a condition in which food takes longer than usual to move from the stomach into the small intestine. This can cause pressure to build up in the stomach, which can lead to acid reflux.
- Certain foods and drinks: Certain foods and drinks, such as spicy foods, fatty foods, citrus fruits, chocolate, coffee, and alcohol, can trigger acid reflux symptoms.
- Pregnancy: Pregnancy can cause acid reflux due to the increased pressure on the stomach from the growing baby.
- Avoiding tobacco and caffeine
- Eating small, frequent meals
- Avoiding foods that trigger acid reflux symptoms, such as spicy foods, fatty foods, and citrus fruits
- Elevating the head of the bed at night