16 Jun How do antacid medication work in patients with gastroesophageal reflux?
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
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.
Routine laboratory studies
Barium swallow (BS), p. 941
Esophageal function studies (EFS), p. 624
Lower esophageal sphincter (LES) pressure
4 mm Hg (normal: 10–20 mm Hg)
Positive in all positions (normal: negative)
Cleared to pH 5 after 20 swallows (normal: <10 swallows)
Normal amplitude and normal progression
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
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?
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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