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Abstract: In this case, a 40-year-old male presented with chest pain, acid reflux, heartburn, and belching, which could be aggravated at night, and were clinical symptoms of reflux-attributable esophagitis. It is caused by factors such as decreased anti-reflux function and reduced esophageal clearance, and may also be related to disease factors such as scleroderma and diabetes mellitus. The prognosis is good after active medical consultation and treatment with medication.
Basic information】Male, 40 years old
Disease Type】Reflux esophagitis
Hospital】Wuhan University Central South Hospital
Date of consultation】February 2020
Treatment plan】Medication (omeprazole enteric capsules, domperidone tablets, thioglycollate aluminum suspension gel, compound amino acid capsules)
Treatment period】1 week of drug treatment
【Treatment effect】After drug treatment, the reflux symptoms were significantly relieved
I. Initial consultation
The patient is a 40-year-old middle-aged male, walking slowly and holding his hand on his abdomen at the time of consultation. He reported the presence of epigastric pain, chest pain, and acid reflux, accompanied by nausea and vomiting, which have affected daily eating and are more obvious at night. He was treated with acid suppressants and gastric mucosal protectors, but his symptoms did not improve significantly, so he came to the hospital for treatment. This time, the diagnosis was still reflux esophagitis, and the patient was recommended to be hospitalized for further examination to clarify the presence of other lesions and for systematic treatment.
II. Treatment history
Gastroscopic examination and whole abdomen plain film were performed after the patient was admitted to the hospital. The results of the gastroscopic examination indicated that short streaks of congested erosions were seen in the lower esophagus without fusion, and the gastric mucosa was congested. The patient was given drugs to inhibit gastric acid, such as omeprazole enteric capsules, as well as gastric mucosal protective agents and pro-gastric motility drugs, such as aluminum thioglycollate suspension gel and domperidone tablets.
III. Treatment effect
The patient’s discomfort symptoms were significantly relieved after drug treatment. After 3 angels of medication treatment, nausea, vomiting and other dyspeptic symptoms were significantly reduced. After 1 week of medication treatment, epigastric pain, chest pain, acid reflux and other discomfort symptoms have been significantly relieved, while nausea, vomiting and other symptoms have been cured, and the patient’s mental state is also better, and can be discharged. However, patients need maintenance treatment after discharge to avoid recurrence of the disease.
IV. Notes
I was very happy to see the patient’s symptoms improve. The patient should avoid strenuous exercise as much as possible in life to avoid aggravating the discomfort, and should do some soothing exercises, such as walking and tai chi, to help physical and mental health. At the same time in the diet as far as possible to eat light and easy to digest food, such as rice porridge, noodles, etc., avoid eating spicy, greasy food, so as not to lead to increased pressure in the stomach, thus aggravating the symptoms of reflux. The head of the bed should also be elevated as much as possible when sleeping so that lying flat does not lead to increased gastric reflux. In addition, patients should also follow the doctor’s prescription for regular medication after discharge to prevent recurrence of the disease due to private discontinuation of medication or change of dosage.
V. Personal insight
Reflux esophagitis is a recurrent disease and is relatively common in clinical practice, so there is no need to worry too much. It is recommended to actively seek medical advice for systematic treatment and regular medication, and the discomfort can usually be significantly improved or even clinically cured. In this case, the middle-aged man had been suffering from the disease for a long time, but his condition was prolonged due to the lack of systematic treatment, but after receiving systematic treatment, his condition was controlled and his prognosis was better.