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Abstract: Xiao Li had abdominal pain and diarrhea with acid reflux and heartburn for 4 years, and reported that he had intermittent treatment with chewable magnesium aluminum carbonate tablets and other medications during this period, with poor results. Anesthesia gastroscopy showed reflux esophagitis and chronic gastritis, and he was hospitalized for 2 days to be treated with acid suppression therapy, oral rabeprazole sodium enteric tablets, pivirimium bromide tablets, and bifidobacterium quadruplex tablets.
Basic information】Male, 29 years old
Disease Type】Reflux esophagitis
Hospital】The First Hospital of China Medical University
Date of consultation】January 2022
Treatment plan】Medication (rabeprazole sodium enteric solution tablets, pivetonium bromide tablets, bifidobacterium tetradecanoidum tablets)
Treatment period】2 days of inpatient treatment, 2 weeks of drug treatment, 6-month outpatient follow-up
Treatment effect] Abdominal distension and abdominal pain disappeared, and the condition was stable
I. Initial consultation
When I first saw Xiao Li, he was depressed and tired. He said that he had abdominal pain and diarrhea with acid reflux and heartburn for 4 years, and he thought it was chronic gastritis, so he did not pay attention to it. I told Li not to be overly nervous and performed a routine examination of Li, and found that the abdomen was soft, with pressure pain in the upper abdomen and left lower abdomen, no rebound pain, and the liver and spleen were not touched under the ribs. Bowel sounds were present and there were no other abnormalities. Based on the clinical symptoms and physical examination, he was initially diagnosed with reflux esophagitis and admitted to the hospital.
II. Treatment history
Xiao Li explained that acid reflux and heartburn suggested the presence of excessive acid reflux, and that he needed to use drugs to inhibit acid secretion and thus reduce acid reflux. Afterwards, the examination was perfected. syphilis antibody, AIDS antibody, hepatitis C antibody were negative, lipid homocysteine 44.54umol/L, renal function urine 532.00umol/L, liver function in the prealbumin 47.90mg/dl, glutamyl transpeptidase 47.58U/L. Anesthesia gastroscopy showed reflux esophagitis, chronic gastritis, and colonoscopy did not show any abnormality. The abdominal pain and diarrhea were considered as irritable bowel syndrome, and Bifidobacterium tetrasporus tablets were given to regulate the gastrointestinal flora.
III. Treatment effect
Xiao Li’s symptoms were significantly reduced after 2 days of hospitalization, no symptoms of abdominal distension and abdominal pain, acid reflux and heartburn were also improved, and the general condition could be considered, so he could be discharged home for drug treatment. Xiao Li went to the outpatient clinic for review after taking the medication at home for 2 weeks, and was found to have a soft abdomen, no abdominal pressure pain as well as rebound pain, and a good gastroscopic examination. The situation of irritable bowel syndrome was improved and Xiao Li’s reflux esophagitis was initially controlled, but regular gastroscopy was needed to observe the condition of gastric mucosa.
IV. Precautions
Xiao Li’s acid reflux and heartburn symptoms were relieved, and I felt relieved for Xiao Li when I saw his happy face. However, since Xiao Li has chronic gastritis, he needs to pay attention to his diet in daily life, avoiding spicy and stimulating diet, not smoking and drinking, and minimizing coffee and chocolate to avoid stimulating the gastric mucosa and causing uncomfortable symptoms. Also pay attention to a full meal, that is, lying down within 3 hours after the meal, when sleeping, you can raise the head of the bed to help reduce the symptoms of acid reflux and heartburn. For diarrhea and abdominal pain caused by irritable bowel syndrome, attention should be paid to good living habits and avoid excessive mental stress, which can help reduce uncomfortable symptoms.
V. Personal insight
The etiology of reflux esophagitis is not clear. It may be related to decreased anti-reflux function and delayed gastric emptying. Typical symptoms are acid reflux and heartburn, which may be accompanied by discomfort such as epigastric pain and belching. The onset of reflux esophagitis is slow in some people, just like Xiao Li who had the disease for 4 years, but did not undergo standardized treatment, but took gastric mucosal protector-type drugs, resulting in recurrent symptoms. Therefore, when the symptoms of discomfort appear, you should go to the hospital in time to avoid reflux esophagitis long-term discomfort, and even lead to complications.