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

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?

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