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Abstract: Chest pain, acid reflux and dysphagia should be examined promptly. Once an esophageal ulcer is found, firstly, the nature of the ulcer should be judged to exclude malignant tumor causing esophageal ulcer, and secondly, the cause of the esophageal ulcer should be actively sought. The patient was admitted to the hospital for chest pain, acid reflux, heartburn and dysphagia, and after standardized treatment to suppress gastric acid and protect the esophageal mucosa, the condition has been controlled and all indicators are improving.
Basic information】Male, 45 years old
Disease Type】Esophageal ulcer
Hospital】Wuhan University People’s Hospital
Date of consultation】December 2021
Treatment plan】Medication (Omeprazole sodium for injection + Omeprazole magnesium enteric dissolved tablets + Aluminum phosphate gel)
Treatment period】Inpatient treatment for 4 days, outpatient follow-up after 2 months
Treatment effect】The disease has been controlled, and all indicators are improving
I. Initial consultation
The patient was admitted to the hospital 5 days ago and had a foreign body sensation in the throat when eating and swallowing, along with significant chest pain, acid reflux, heartburn, and dysphagia, which could be relieved after lying down and resting, and intermittent episodes of chest pain and back pain at night, affecting sleep. The patient came to the outpatient clinic, and after detailed medical history, it was found that the patient usually eats quickly and inadvertently ingested chicken bones 6 days ago. Combining the medical history and the patient’s performance, the patient was considered to have a possible esophageal lesion and was advised to undergo gastroscopy. The gastroscopy suggested middle esophageal ulcer and chronic non-atrophic gastritis, and tissue was taken from the ulcer site for biopsy, and the patient was admitted to the hospital for further diagnosis and treatment.
II. Treatment history
After the patient was admitted to the hospital, it was especially important to identify the benign and malignant nature of the esophageal ulcer, and the two treatment plans were very different. After fully informing the patient of the treatment idea, relevant examinations were performed, and the results indicated that: routine blood, AFP, CEA, CA199, liver and kidney function electrolytes were not significantly abnormal, electrocardiogram: no significant abnormality, H. pylori examination: C14 breath test was negative, chest and abdomen CT did not show significant abnormalities, esophageal ulcer disease examination results: chronic inflammation. Combined with the patient’s history of swallowing chicken bones, the esophageal ulcer was considered to be caused by a foreign body (chicken bones) damaging the esophageal mucosa. The patient was given sodium omeprazole for injection to suppress gastric acid, aluminum phosphate gel to protect the esophageal mucosa, and a liquid diet.
III. Treatment effect
After 4 days of drug treatment, the patient’s symptoms were significantly relieved, so he was discharged from the hospital and ordered to take oral omeprazole magnesium enteric tablets + aluminum phosphate gel outside the hospital. At the follow-up visit 2 months after discharge, the patient complained that the foreign body sensation in the throat and the soreness in the back of the chest, acid reflux and heartburn had basically disappeared without any special discomfort. The patient was advised to repeat gastroscopy, which showed that the esophageal mucosa was normal and the esophageal ulcer had healed.
IV. Notes
We are glad that the patient’s symptoms were relieved after treatment. After the patient was discharged from the hospital, he was instructed to pay attention to his diet, mainly a liquid or semi-liquid diet, avoid eating too fast, avoid overeating, avoid spicy and stimulating foods, and prohibit smoking and alcohol. At the same time, they need to take regular drugs to inhibit stomach acid and protect esophageal mucosa, pay close attention to the changes of symptoms such as acid reflux, heartburn and chest pain, and observe the color of stool. If there is an aggravation of symptoms and black stool, they should follow up with the hospital in time to facilitate the timely detection of complications such as combined bleeding of esophageal ulcer.
V. Personal insight
When patients present with chest pain and other manifestations, esophageal disease, coronary heart disease, pulmonary disease and other causes should be considered, and active differential diagnosis is required. When it is clear that the patient is suffering from chest pain due to esophageal ulcer, the first step is to identify the benign and malignant nature of the esophageal ulcer so that the next treatment plan can be decided. For benign esophageal ulcers, the etiology and causative factors, such as foreign body scratching the esophageal mucosa, gastroesophageal reflux, immune disorders, and bacterial infections, should be actively sought. In combination with the patient in this case, a detailed history was taken, and it was found that chicken bones had been eaten the day before the chest pain, which was more helpful in diagnosing foreign body-induced esophageal ulcers and also clarified the next treatment plan.