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Abstract: A 60-year-old woman, Mrs. Zhou, sought medical attention because she had been suffering from abdominal pain with indigestion, acid reflux, and belching. After completing relevant examinations, she was initially diagnosed with chronic superficial gastritis and duodenal bulb ulcer, which in turn caused intestinal spasm, resulting in abdominal pain and dyspepsia, and was given oral medication for 2 weeks, with significant relief of symptoms.
Basic information】Female, 60 years old
Disease Type】Intestinal spasm, duodenal ulcer
Hospital】Wuhan University Central South Hospital
Date of Consultation】January 2022
Treatment plan】Oral medication (omeprazole enteric capsules, amoxicillin capsules, bismuth citrate potassium tablets, clarithromycin tablets, trimebutine maleate tablets)
Treatment period】Regular treatment for 2 weeks, review after 1 month
Treatment effect] The abdominal pain has completely disappeared, no acid reflux, belching and other discomfort
I. Initial consultation
In the afternoon, a 60-year-old woman, Mrs. Zhou, visited the doctor because she had been suffering from abdominal pain. According to Mrs. Zhou, she had been experiencing abdominal pain with or without meals for the past few days, and the pain was not regular in duration, so she did not know what caused it. During the exchange with Mrs. Zhou, I also learned that she had indigestion and sometimes acid reflux and belching, but she had not been treated because it was not serious. I suspected that Mrs. Zhou’s symptoms were gastrointestinal diseases, but no abnormalities were found through physical examination, and further tests were needed to clarify them.
II. Treatment
Mrs. Zhou was advised to undergo routine blood tests, gastroscopy, triple gastric function tests, and carbon 14 breath tests, which revealed the presence of chronic superficial gastritis and duodenal bulb ulcers, usually due to H. pylori infection. Initially, it was determined that Mrs. Zhou’s main abdominal pain was due to intestinal spasm caused by duodenal ulcer. After explaining her condition to Mrs. Zhou, I suggested her to take a quadruple medication for H. pylori infection, including omeprazole enteric capsules, amoxicillin capsules, bismuth citrate potassium tablets and clarithromycin tablets, as well as trimebutine maleate tablets to regulate the gastrointestinal tract and inhibit gastrointestinal spasm to relieve abdominal pain. After 1 month, a carbon 14 breath test should be performed again to check whether H. pylori is completely cleared.
Treatment effect
After taking the above drugs for 1 week, Mrs. Zhou came to our hospital for a follow-up consultation and complained that her condition gradually recovered, her intestinal cramps were effectively controlled, her abdominal pain symptoms were significantly improved, the number of attacks was reduced, and acid reflux and belching were less frequent. Because of the good effect of medication, I instructed Mrs. Zhou to continue the medication treatment. When she came back to our hospital one week later, she said her abdominal pain had completely disappeared and her food digestion was better, with no more acid reflux or belching. The gastroscopic examination showed that Mrs. Zhou’s gastrointestinal tract was in good shape, so I determined that she had recovered well and could stop the medication temporarily. 1 month later, Mrs. Zhou’s carbon 14 test was negative, indicating that H. pylori had been eradicated, so she was instructed to stop the medication.
IV. Notes
We are glad that Mrs. Zhou’s condition has improved, but we need to advise her to eat more fresh vegetables and fruits in her daily diet, avoid pickled, smoked, fried and spicy foods, and maintain a low-salt and low-fat diet, which is beneficial to her recovery from stomach disease. In addition, Mrs. Zhou’s condition was not very serious, so she was advised not to worry too much, to keep a calm attitude, and to follow the doctor’s instructions to take medication, but to avoid adding or subtracting medication without permission, so as to avoid decreasing the treatment effect and prolonging her condition.
V. Personal insight
Helicobacter pylori infection is a common cause of gastritis and peptic ulcers, which are common factors causing intestinal cramps. The 60-year-old Mrs. Zhou developed chronic atrophic gastritis and duodenal bulb ulcers after being infected with Helicobacter pylori. Previously, when Mrs. Zhou had indigestion, acid reflux and belching, the symptoms were ignored because they were not serious and infrequent. However, stomach disorders should be treated promptly whenever symptoms appear, so as not to lead to the progression of the disease and induce other diseases.