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Abstract: The patient in this case is a 45-year-old male who has been smoking and drinking alcohol for a long time and had difficulty eating and other uncomfortable symptoms more than six months ago. After a series of tests, the patient was diagnosed with reflux esophagitis and was treated with medication.
Basic information】Male, 45 years old
Disease Type】Esophagitis
Hospital】The First Hospital of China Medical University
Date of consultation】April 2020
Treatment plan】Intravenous injection (omeprazole sodium for injection) + oral medication (teprenone capsules, domperidone tablets, omeprazole enteric-coated tablets)
Treatment period】1 week hospitalization, continuous follow-up
Treatment effect】The condition improved and the discomfort symptoms basically disappeared.
I. Initial consultation
The patient is a 45-year-old male with a 20-year history of smoking and alcohol consumption. He complained of difficulty in eating, vomiting after eating, and sometimes bilateral subcostal paroxysmal vague pain without chest pain, heartburn, acid reflux, and obvious obstruction more than half a year ago without any obvious cause. Today, he came to the hospital for further treatment. Gastroscopic examination showed that the mucous membrane of the esophagus was congested and edematous, and there was an ulcerated surface, so the diagnosis of reflux esophagitis was confirmed.
II. Treatment history
After admission, a differential diagnosis was made to clarify the case of reflux esophagitis, and the patient and his family were introduced to the patient’s condition in detail, and the current treatment options were explained to them. After discussion with the patient and his family, they decided to perform medication. In response to the patient’s condition, it was decided to give injectable omeprazole sodium to inhibit gastric acid secretion; teprenone capsules to protect the gastric mucosa; and domperidone tablets to promote esophageal peristalsis and accelerate gastric emptying. After 1 week of hospitalization, the patient was discharged from the hospital to take omeprazole enteric soluble tablets, teprenone capsules and domperidone tablets at home to consolidate the treatment and to follow up regularly.
III. Treatment effect
After 1 day of admission, the patient could eat; after 4 days of continuous treatment, vomiting and subcostal paroxysmal vague pain basically disappeared, and eating also basically returned to normal; on the 6th day of hospitalization, the gastroscopy was repeated, indicating that the subscopic esophageal mucosal congestion and edema disappeared, and the ulcer surface basically healed, and the patient basically recovered, so the patient agreed to be discharged. Two months after discharge, the gastroscopy was repeated in the outpatient clinic, and the microscopy showed no obvious abnormalities in the esophageal mucosa, and the discomfort symptoms reported by the patient basically disappeared, indicating that the treatment effect was good and the patient basically improved.
IV. Notes
After the patient was admitted to the hospital, his condition improved and he could basically eat normally without vomiting after eating, and his complexion was healthier than before he was admitted. I also advised the patient that although he has basically recovered from reflux esophagitis, he still needs to improve his living and eating habits, try to wake up early and go to bed early, work and rest regularly, have regular meals, gradually reduce the amount of smoking and alcohol consumption, and gradually refrain from smoking and drinking. In addition, it is not recommended to eat spicy, too hot, too acidic food, because reflux esophagitis is prone to recurrence, daily attention to do a good job of prevention in order to reduce the recurrence rate of the disease. Finally, it is recommended to review the gastroscopy once a year, and if there is any abnormality, timely targeted treatment.
V. Personal insights
Among esophagitis, reflux esophagitis is the most common, and the incidence is on the rise, especially in people who smoke and drink alcohol for a long time, similar to the patient in this case, the diagnosis of the disease is closely related to bad daily habits. Therefore, to prevent the disease, or to reduce the recurrence rate of the disease, you should adjust your diet and lifestyle habits, strictly avoid smoking and alcohol, eat a healthy diet, and reduce the stimulation of the stomach and intestines by external factors.