(Disclaimer: This article is for scientific use only, and the information in the following content has been processed to protect patient privacy)
Abstract: A 41-year-old male patient came to our hospital 3 years ago with no obvious cause of panic and chest tightness, mostly at night during sleep, with acid reflux and chest pain, occasional cough, no nausea or vomiting, and no significant improvement after treatment at a local hospital. After completing relevant examinations, the patient was diagnosed with reflux esophagitis, which is a common esophageal disease. After standard treatment with drugs, the patient’s symptoms of panic, chest tightness and acid reflux were significantly relieved, and his mental state was good.
Basic information】Male, 41 years old
Disease Type】Reflux esophagitis
Hospital】The 988th Hospital of the PLA Joint Logistics and Security Forces
Date of consultation】September 2021
Treatment plan】Intravenous (sodium rabeprazole for injection) + oral medication (mosapride citrate tablets)
Treatment period】5 days of inpatient treatment, six months of outpatient follow-up
Treatment effect] The patient’s symptoms of panic, chest tightness and acid reflux were significantly relieved, her mental state was good, and her nighttime sleep returned to normal.
I. Initial consultation
The patient is a 41-year-old male with a history of “hepatitis B” for many years, with normal liver function and abdominal ultrasound indicating no occupying lesions in the liver, gallbladder, pancreas and spleen. The patient complained of frequent panic attacks, chest tightness, acid reflux, chest pain, and occasional coughing at night during sleep for the past 3 years, but the symptoms were significantly reduced or relieved during the day. Recently, the symptoms worsened, so he came to our hospital for consultation. After detailed medical history, although the patient had a history of “hepatitis B”, repeated liver function tests and abdominal ultrasound did not show any abnormality, so the discomfort caused by “hepatitis B” was excluded. Reflux esophagitis was confirmed.
Treatment history
The patient had been suffering from intermittent panic attacks and chest tightness for about 3 years, and the symptoms were not relieved by long-term treatment, so he was stressed, depressed and anxious, and always worried about sudden death due to “heart disease”. In order to further understand the condition, gastroscopy was performed, suggesting that a strip of mucosal erythema was seen above the dentate line of the lower esophagus, with a maximum length of about 0.5 cm, the surface was slightly congested, the lesion was not fused, and an island of red ectopic mucosa with clear vascular texture was seen. The patient was given injectable sodium rabeprazole to inhibit gastric acid secretion and mosapride citrate tablets to promote gastrointestinal motility, as well as psychological counseling to relax, and the patient’s symptoms of panic, chest tightness and acid reflux were gradually relieved without cough and chest pain.
III. Treatment effect
The patient was given drugs to inhibit gastric acid secretion and promote gastrointestinal motility for 5 days, and his symptoms of panic, chest tightness, acid reflux and chest pain were significantly relieved, and he had no fever, cough and other symptoms. The patient was discharged after 5 days of hospitalization and was instructed to follow up for six months.
IV. Notes
We are glad that the patient’s esophageal disease was effectively treated, and the patient was instructed to pay attention to the following conditions in daily life.
1. avoid overeating, do not overeat, do not lie down immediately after meals, and do not eat within 2-3 hours before bedtime.
2, abstain from smoking and alcohol, avoid spicy and stimulating foods such as chili, coffee, fatty meat.
3, obese people to lose weight properly, avoid factors that lead to increased abdominal pressure, such as long-term cough, constipation, etc..
4, maintain a good mood, if there is discomfort, promptly seek medical advice to avoid delaying the disease.
V. Personal insight
Reflux esophagitis is an inflammatory esophageal lesion caused by the reflux of gastric and duodenal contents into the esophagus. Common symptoms include heartburn, chest tightness, or epigastric discomfort and pain. Some patients may have symptoms such as heartburn and chest tightness like the patient in this article, mostly after meals or during sleep at night, with a high incidence of long-term smoking, alcohol consumption, mental stress and obesity. This disease can be prevented and controlled, usually pay attention to strengthen the awareness of the disease and reduce the triggering factors.