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Abstract: Uncle Liu came to our hospital with the discomfort of acid reflux and heartburn, occasional epigastric pain, flatulence, and belching since 1 year ago, and recently the discomfort worsened. After diagnosis, Uncle Liu was considered to have reflux esophagitis, and was given mosapride citrate tablets and rabeprazole sodium enteric capsules for treatment, and his symptoms improved and his condition was controlled after taking the medication.
Basic information】Male, 53 years old
Disease Type】Reflux esophagitis
Hospital】The First Hospital of China Medical University
Date of consultation】February 2022
Treatment plan】Medication (mosapride citrate tablets, rabeprazole sodium enteric capsules)
Treatment period】2 days of hospitalization and 8 weeks of drug treatment
Effectiveness of treatment] Acid reflux and heartburn symptoms improved, and the disease was basically controlled
I. Initial consultation
When he first met Uncle Liu, he was rather tired and started to describe his condition anxiously when he saw me. He reported that he had acid reflux and heartburn a year ago, with occasional epigastric pain, flatulence and belching discomfort, a history of chronic gastritis, and a history of hypertension for many years. Uncle Liu at first thought that acid reflux and heartburn were the reason for taking drugs and did not take them seriously, but recently the discomfort worsened, so he came to the hospital. The abdomen was found to be soft, with pressure pain in the upper abdomen but no rebound pain, the liver and spleen were not palpable under the ribs, and intestinal sounds were present.
II. Treatment process
After hospitalization, Uncle Liu underwent professional examination, and gastroscopy revealed esophageal hiatal hernia with esophagitis (L-B) and chronic pulmonary atrophic sinusitis with nodules. After admission and timely treatment to suppress gastric acid and reduce reflux, i.e., drug treatment with mosapride citrate tablets and rabeprazole sodium enteric capsules. At the same time, the tests were negative for syphilis antibody, hepatitis C antibody and AIDS antibody, and no significant abnormality was found in the cranial CT scan. After 2 days of hospitalization, he went home and continued to take medication, and gastroscopy was repeated after 8 weeks of medication.
III. Treatment effect
After 1 day of hospitalization, Uncle Liu’s symptoms of acid reflux and heartburn were relieved. After 2 days of hospitalization, there were no uncomfortable symptoms of abdominal distension and abdominal pain, occasional acid reflux and no symptoms of heartburn. Examination revealed that the abdomen was soft and there was no pressure pain, so he could be discharged home to continue medication. Uncle Liu went home to the outpatient clinic for review after 8 weeks of taking medication, and the examination revealed that the abdomen was soft, no pressure pain, and the gastric mucosa was light red on gastroscopy, and the gastric mucosa was smooth and soft, i.e., no significant abnormality was seen in the gastric mucosa. However, since Uncle Liu has chronic gastritis, he needs to be reviewed regularly at a later stage.
IV. Notes
Uncle Liu was very happy after the treatment and reported that he did not have to suffer from acid reflux and heartburn, and I felt relieved for Uncle Liu. However, since Uncle Liu also has a history of chronic gastritis, I advised him to pay attention to a low-salt diet and actively reduce his weight in daily life. Elevating the head of the bed when sleeping and avoiding lying flat within 2 hours after a meal will help avoid the recurrence of reflux esophagitis. The diet also needs to avoid spicy and irritating foods, no smoking and drinking to avoid irritating the gastric mucosa, which can easily cause recurrence of the disease. Also, Uncle Liu has a history of chronic gastritis and needs to undergo regular gastroscopy so as to dynamically observe the condition.
V. Personal insight
The etiology of reflux esophagitis is not clear. It may be related to aspects such as reduced esophageal clearance ability and abnormal esophageal sensation, and the typical symptoms are acid reflux and heartburn. When there are symptoms of stomach discomfort, such as acid reflux, heartburn, bloating, abdominal pain and other discomfort, you should go to the hospital in time for the appropriate examination to avoid delaying treatment, which may aggravate the disease, thus easily prolonging the treatment time and is not beneficial to the treatment effect. Uncle Liu is the appearance of discomfort symptoms, has not been taken seriously, because he suffers from high blood pressure, chronic gastritis, it is thought that the usual taking drugs caused by discomfort symptoms, until the discomfort symptoms aggravated, only to the hospital for treatment, which delayed the treatment time, but also affect the quality of life.