(Disclaimer: This article is for scientific use only, and the information in the following content has been processed to protect patient privacy)
Abstract: A 45-year-old female patient presented with vomiting and diarrhea without any cause, and was diagnosed with acute gastroenteritis and esophagitis after examination. After treatment with anti-infection, acid suppression and rehydration, the patient’s condition stabilized and she was discharged successfully. Esophagitis is mostly caused by irritation or injury to the mucosa of the esophagus, the most common of which is gastric acid irritation. Patients are advised to protect their intestines and stomach and pay attention to their diet on a regular basis to prevent the occurrence of esophagitis.
Basic Information】Female, 45 years old
Disease Type】Esophagitis
Hospital】The First Hospital of China Medical University
Date of consultation】September 2021
Treatment plan】Medication (Famotidine injection, potassium chloride injection, vitamin C injection, vitamin B6 injection, magnesium sulfate, bismuth citrate potassium capsule, aluminum thioglycollate suspension gel, omeprazole enteric solution capsule, vernorasen fumarate tablet)
【Treatment cycle】7 days of hospitalization + 2 weeks of follow-up
Treatment effect】The patient’s condition was stable, acid reflux, heartburn, nausea and vomiting were relieved, and she was discharged successfully.
I. Initial consultation
The patient complained of vomiting with no obvious cause 6 days ago, and the vomit was stomach contents, no persistent food, no blood or coffee-like substance. 5 days ago, he had diarrhea with no obvious cause, 2-3 times/day, starting with paste-like stool, then gradually changed to yellow thin stool, no mucus-purulent stool, blood stool, black stool, and indicated heartburn and painful swallowing. I gave the patient basic examination, the patient’s abdomen was soft, epigastric pressure pain, no rebound pain, the rest of the abdomen had no pressure pain, rebound pain, and no abdominal mass. Abdominal percussion showed drum sound, no percussion pain in the liver and kidney area, no mobile turbid sounds, and active bowel sounds, about 5-7 times/min. The patient’s pharyngeal mucosa was not congested, the tonsils were not enlarged, the carotid artery pulsation was normal, the jugular vein was not angry, and the breath sounds of both lungs were clear. The patient was then given routine blood and stool tests, which returned elevated leukocytes, neutrophils, basophil ratio, erythrocytes, hemoglobin and platelets, and positive fecal occult blood. Combining the laboratory results with the patient’s basic physical findings I made a preliminary diagnosis of esophagitis. The patient was advised to be admitted to the hospital for treatment, and the patient agreed. The patient was admitted to the hospital and gastroscopy was completed. During the examination, it was seen that the esophageal mucosa was white in color, rough on the surface, and small patches of mucosa were visible about 29 cm from the incisors with red, clear borders, and tea-brown changes in the NBI. The mucosa of the gastric fundus was unevenly orange-red, congested and edematous, with normal fold morphology and distribution, and cloudy mucus in medium volume. The gastric angle was curved and soft; the mucosa of the gastric sinus was unevenly colored, congested and edematous. According to the results of gastroscopy, the diagnosis was clearly acute enteritis; esophagitis; and chronic gastritis.
II. Treatment history
After the patient was admitted to the hospital, I gave him famotidine injection with 0.9% sodium chloride injection intravenously to inhibit gastric acid secretion. At the same time, potassium chloride injection, vitamin C injection and vitamin B6 injection were infused intravenously to ensure electrolyte balance in the patient’s body. During the infusion of potassium chloride injection, the patient complained of swelling and pain at the infusion site. I told the patient that potassium chloride was an irritant drug and the infusion process might cause discomfort, and then gave the patient magnesium sulfate wet compresses and slowed down the drip rate. After the patient’s vomiting symptoms improved, I instructed the patient to eat several times, and try to choose light and easily digestible liquid food or semi-liquid food to protect the gastrointestinal tract, the patient expressed positive cooperation, and the symptoms gradually improved.
III. Treatment effect
The patient was hospitalized for 7 days and had no special discomfort. He complained of relief of heartburn, improvement of pain when swallowing, no nausea and vomiting after eating, and no abdominal pain. The patient was examined before discharge as well as routine blood and stool tests, and the findings were no pressure pain in the upper abdomen, no rebound pain, no pressure pain or rebound pain in the remaining abdomen, and no abdominal mass. The liver and spleen were not palpable under the ribs, and Murphy’s sign was negative. The abdomen showed drum sound on percussion, no percussion pain in the liver and kidney area, no mobile turbid sounds, normal bowel sounds, and no edema in both lower limbs. The routine blood indicators were normal and the stool routine was negative for fecal occult blood, so the patient was discharged. Two weeks after the patient was discharged from the hospital, a telephone follow-up was conducted, and the patient expressed good recovery, good appetite, no special discomfort, and satisfaction with the treatment process.
IV. Notes
The patient’s condition was stable during his hospitalization, and I was sincerely happy for the patient, and I actively provided health education to the patient before discharge. I told the patient that he should continue to take bismuth potassium citrate capsule and aluminum thioglycollate suspension gel to protect the gastric mucosa, omeprazole enteric capsule and vernonasen fumarate tablet to inhibit gastric acid, and the above drugs can protect the gastrointestinal tract and esophagus to consolidate his condition. After discharge from the hospital, pay attention to rest, avoid straining, and continue drug treatment, adhere to the course of treatment and medical advice to take drugs to avoid recurrence of the disease. Pay attention to improve dietary habits, can eat less and more meals, low salt and low fat, light and easy to digest diet, avoid spicy and stimulating food or drinks, do not lie down immediately after meals, should walk to promote stomach digestion, and avoid squatting, bending and other actions that increase abdominal pressure to avoid food reflux. Enteritis, gastritis, and esophagitis are prone to recurrence, so a six-month gastroscopy review is recommended to monitor the condition.
V. Personal insight
For esophagitis, the most common clinical condition is reflux esophagitis, which is the reflux of gastric and duodenal contents that irritate the esophageal mucosa and cause it to develop inflammatory lesions. The patient in this article was suffering from prolonged vomiting, which resulted in damage to the esophageal mucosa and thus caused esophagitis. If esophagitis is not actively treated, it may lead to esophageal stricture and symptoms such as dysphagia, chest pain, and heartburn. Therefore, gastroscopy is recommended every 3 years for young patients, and once a year for patients like the one in the article, who are already middle-aged, to prevent gastrointestinal diseases.