On the morning of Sept. 20, the day after his GERD surgery, Cai Zhengsong’s cough and hiccups subsided and he began to smile. The cough and hiccups were significantly reduced, and a smile began to be written on his face.
Previously, he had been hospitalized for 10 days and was treated by the respiratory doctors for “acute bronchitis” and “mild emphysema”, and had undergone infusion, sputum removal, cough suppression, anti-inflammation, and oxygen care… …but still couldn’t stop retching and coughing. Liu Dengke Cai Zhengsong of the Department of Spleen and Gastrointestinal Diseases (Gastroenterology) of Wangjing Hospital, Chinese Academy of Traditional Chinese Medicine, had a dry cough every time he had an attack, which sounded “scary” to his wife, Lu Chunying. She later learned that it was due to the constant irritation of the throat by refluxed stomach acid. As for the history of hiccups, it has been more than a decade, and most of them occur at night. “As soon as the lights were turned off, Cai’s body began to flow, “and he would fight endlessly,” and very often he would be suffocated and unable to burp. “This made Lu Chunying very worried, “afraid that he would pass at any time”.
This time, after coughing for half a month, Cai was admitted to the Second Artillery General Hospital in Xiaoxitian, Beijing. An unintentional wander around in front of the inpatient building by Chunying Lu changed the direction of her husband’s treatment. She saw a bulletin board about GERD and approached the chief of the respiratory department, hoping they would consult with a gastroenterologist. After 24-hour PH monitoring and barium meal tests, Cai was diagnosed with GERD.
Guo Xiuying has had the same disease for a longer time than Cai Zhengsong, almost 34 years, and her symptoms are somewhat different. At that time, she was 35 years old, “everything she ate was regurgitated, even a sip of water was vomited, and she was so thin that she was skin and bones”. Later, she was prescribed some medicine by a Chinese medicine doctor, but her condition was still getting better and worse. In March this year, she suddenly developed angina and was diagnosed with coronary heart disease, with the coronary arteries narrowed “like a toothpick”. After spending 70,000 yuan to implant three coronary artery stents, the doctor recommended that more watermelon be eaten to diuretic. As a result, just after eating half a watermelon, Guo Xiuying began to cough so violently that the wound in the artery on her wrist was torn open and blood flowed all over the floor. For more than two months afterwards, Guo Xiuying was unable to sleep at night, coughing constantly and swelling all over her body.
In May 2005, she was diagnosed with “In May 2005, she was diagnosed with “chronic superficial gastritis” and underwent a gastroscopy, but the doctor said “it’s okay not to take medicine. Liu Li Li still ate a lot of medicine, “all to no avail”. In May this year, the sleeping Liu Li Li was awakened for four or five days in a row, coughing and vomiting for an hour or two. “What other organ is between the throat and the stomach?” Once at a clinic visit, she asked the doctor in a hoarse voice, “I only have difficulty here.” The doctor reminded her: could it be reflux esophagitis?
A treatment center was established after the hospitalist was misdiagnosed.
All three patients later found their way to the GERD Center at the Second Artillery General Hospital. The center’s director, 68-year-old Chinese Academy of Sciences academician Wang Zhonghao, is a renowned vascular surgeon. The reason for creating the center was that Wang himself was once a patient who suffered from GERD and was also misdiagnosed.
Two years ago, Wang developed a persistent cough, runny nose and sneezing, and was told with “certainty” by his otolaryngologist that it was “typical allergic rhinitis”. After taking a variety of drugs, Wang Zhonghao’s condition got worse instead of lighter, and he gradually developed symptoms such as tightening of the throat and difficulty in breathing.
From January to October 2005, Wang was sent to the hospital four times because he had extreme difficulty breathing at night. Each time, he was diagnosed as having an acute attack of bronchial asthma, or with the diagnosis of chronic laryngitis, acute bronchitis, sleep apnea syndrome, etc. He was then given oxygen, bronchodilation, intravenous or oral cortisone, and other treatments. The symptoms were really relieved in a short time. But when he went home, he would still wake up suffocating, coughing, spitting and “dying” once he slept until two o’clock at night. On February 9 of this year. He went to a dental appointment where the doctor asked him to keep his mouth open and constantly sprayed water into his periodontium and mouth. Perhaps stimulated by this, upon his return to the office, Wang Zhonghao suffered a seizure so severe that the hospital issued a critical illness notice to his family. This time, he was still diagnosed by doctors as having an “acute attack of bronchial asthma”.
After his condition went into remission, Wang began to seriously consider a warning from a foreign medical colleague.
In 2004, Wang was in India for a meeting, and during the banquet, he kept leaving the table, sometimes covering his mouth and hurrying away. Wang later explained, “I actually have extremely strong willpower, but at the dinner table, it was remarkable that I could sit for 5 or 10 minutes straight. When the illness struck, I couldn’t control it at all, and I didn’t know when I would throw up.” This scene was seen by one of the medical advisors to the Prime Minister’s minister. In September 2005, when he came to Beijing for a meeting, he ran into Wang again and told him straight away.
Wang Zhonghao seriously considered the medical advisor’s opinion and had a GERD test on October 22, 2005, including 24-hour PH monitoring of the esophagus. The doctor found that in the 21 hours and 23 minutes recorded, Wang Chung-ho had 220 refluxes, with a total reflux time of 169 minutes, accounting for 9.7% of the total time, and 7 refluxes of more than 5 minutes in length, with the longest reflux time of 40.3 minutes. The normal value of the acid reflux score, calculated by combining all parameters, was <14.72, and was classified as moderate between 50 and 100, with a result of 84.4 recorded by Wang Zhonghao's monitoring. Thus, the cause of the disease that had tormented Wang Zhonghao for more than a year was finally diagnosed as GERD.
On March 26, 2006, with the help of his friends, he went to the United States to undergo a free fundoplication, and his symptoms disappeared and his voice, previously mildly hoarse, cleared up.
The day after the surgery, Wang Zhonghao started writing a series of articles including “It’s GERD, not asthma”, taking into account his own experience, and upon his return to China, he set up the first GERD center in China. To date, the center has treated 39 patients, more than half of whom have been chronically misdiagnosed. A 36-year-old woman with persistent lung infection due to reflux had her left lung removed by a local hospital nine years ago for pulmonary atelectasis.
Misdiagnosis rates range from 20 to 40 percent nationally and internationally.
Chen Xiaohong, editor-in-chief of the Journal of Clinical Misdiagnosis and Misdiagnosis, who has long focused on the study of misdiagnosis, found that in the 1920s to 1990s, the clinical misdiagnosis rate at home and abroad had been hovering between 20% and 40%.
Chen Xiaohong and colleagues once collected 548,400 cases, of which 152,934 were misdiagnosed, and analyzed and summarized 16 causes of misdiagnosis, the main reasons of which include: doctors’ inexperience and lack of knowledge of the disease; doctors’ lack of meticulous consultation and physical examination; doctors’ failure to select specific examination items; over-reliance or superstition on the results of auxiliary examinations; patients’ lack of specific symptoms and signs, etc.
In Chen’s opinion, “the phenomenon of treating the head when the head aches and treating the foot when the foot hurts is very common among doctors”. She believes that some GERD patients exhibit respiratory symptoms, and respiratory doctors do not think that the cause could be in the gastrointestinal tract. The definition of gastroesophageal reflux disease usually uses the expression: symptoms or tissue damage such as acid reflux, regurgitation, heartburn due to the reflux of stomach and duodenal contents into the esophagus, with some patients having manifestations outside the esophagus.
According to Professor Xie Pengyan, director of the Department of Gastroenterology at Peking University First Hospital, anyone can occasionally experience gastroesophageal reflux, such as drinking too many drinks containing gas or sleeping after a full meal, “but this is a normal physiological phenomenon, and gastroesophageal reflux disease is associated with a disorder of the dynamics of the upper intestine and stomach”.
At the junction of the esophagus and stomach there is a physiological sphincter called the lower esophageal sphincter, which is a high-pressure band about 3 to 5 cm long, except when swallowing, nausea and vomiting open, usually it is always closed. Its pressure at rest and during swallowing is higher than the pressure in the stomach, so, as Xie Pengyan said, the lower esophageal sphincter is a barrier that prevents the stomach contents from flowing back into the esophagus.
When its function is weakened and there is prolonged spontaneous relaxation, the pressure decreases and gastric contents may break through the barrier. Some studies have shown that this is the main mechanism causing reflux. According to Peng-Yan Xie, excessive mental stress, drug stimulation, smoking, drinking alcohol, tea, peppermint candy and chocolate may lower the pressure of the lower esophageal sphincter to induce reflux.
According to several doctors, refluxed gastric acid and bile are very corrosive, and the esophageal mucosa is poorly acid-resistant, making it difficult to resist damage to the esophagus from refluxed material, which over time can lead to inflammation, ulceration, erosion, or even cancerous esophageal stricture. Feng Zitan, director of the Department of Gastroenterology at Baiqiu’en International Peace Hospital, once saw a patient with severe reflux whose entire esophagus “looked like it had been scalded by boiling water”.
If a patient has this kind of reflux esophagitis, it can be easily detected through upper gastrointestinal endoscopy. But Xie Pang Yan learned that a 2002 survey in Hong Kong showed that as many as 90 percent of reflux patients had non-erosive esophagitis. That is, these GERD patients with negative endoscopy had increased mucus and saliva secretion from the esophageal wall, strengthening the resistance of the esophageal wall to attack factors and making it difficult to confirm the diagnosis.
If significant reflux is detected or monitored by PH, it should be possible to diagnose reflux disease. However, such detection is not easy. Meiyun Ke, a professor of gastroenterology at Peking Union Medical College Hospital, has long been concerned about reflux disease, and she has written an article suggesting that “there are still some patients who cannot yet be detected because they have negative results on these tests. Patients with reflux disease are prone to reflux two hours after a meal or while lying down at night, but this is not the case in all patients. If PH monitoring is performed, how are those who do not experience reflux in 24 hours diagnosed? Other patients with low reflux but significant symptoms and negative tests are visceral hypersensitivity patients, and these patients are also not easily diagnosed.”
If a patient presents with typical symptoms such as heartburn (heartburn), acid reflux, or regurgitation, he or she is much less likely to be misdiagnosed. But some professors of gastroenterology complain that it is those extraesophageal manifestations that make the diagnosis of GERD much more difficult to confirm.
The Journal of Clinical Misdiagnosis and Malpractice collected bulk case reports and dozens of case studies on misdiagnosis of the disease and found that GERD exhibits symptoms involving more than a dozen conditions.
Numerous studies and clinical confirm that when gastrointestinal contents reflux into the pharynx, they can form fine particles or mists that enter the larynx, are inhaled into the trachea, bronchi and lungs, causing otolaryngolaryngeal disease, bronchial asthma and idiopathic interstitial pulmonary fibrosis, and sleep apnea syndrome, which can be misdiagnosed. A study in the United States showed that reflux was one of the top three causes of chronic pharyngitis of unknown origin. And Feng Zitan introduced data showing that about 1/3 or more of asthma patients are associated with reflux. Some GERD patients are also easily misdiagnosed as coronary heart disease because of chest pain.
The misdiagnosis rate is difficult to count because misdiagnosed GERD patients are scattered in respiratory, cardiovascular, ENT and even dental departments. However, several medical professors estimate that the number will be high.
A large number of patients have not yet been identified.
According to Professor Xie Pengyan, the discovery of GERD can be traced back more than 100 years abroad, but the disease was not well understood in China until the 1980s. Chen Xiaohong and some researchers screened out 100 common misdiagnoses of the disease in 1993, and there was no gastroesophageal reflux disease yet.
The editorial board of Clinical Misdiagnosis and Mistreatment conducted a search of the domestic literature on the misdiagnosis and mistreatment of GERD in the last 10 years and unfortunately found that: the incidence and the rate of missed misdiagnosis have not yet attracted enough attention from the medical community.
What is often cited is an epidemiological survey of reflux symptoms conducted by Professor Pan Guozong and others at Peking Union Medical College Hospital in Beijing and Shanghai in 1996 with a sample size of nearly 5,000 people, which showed that the incidence of symptoms was 8.97% and the morbidity rate was 5.77%. The incidence rate in the United States and Europe is as high as 15 to 20 percent, and the United States spends $1.9 billion annually to treat GERD.
One day in April 2006, Chen Xiaohong received a letter of recommendation from academician Qiu Fazu, recommending an article on the experiences of academician Wang Zhonghao who suffered from GERD. Chen Xiaohong put the articles of the two academicians on the “China Health Network”, which specializes in misdiagnosis research, and opened a special topic of “Concerning GERD”. She hopes that all doctors will tell us their misdiagnosis cases.
Xie Pengyan said that in the outpatient clinic of the Department of Gastroenterology at Peking University First Hospital, most of the patients who come to the hospital because of acid reflux and heartburn are related to reflux, and these patients account for about 1/4 of the entire outpatient volume.
But for the diagnosis and pathogenesis of GERD, Xie Pengyan believes that “there is still a lot that is not very clear”. In terms of treatment, “there is no medicine that is too ideal”, and for new technologies such as radiofrequency therapy, “the long-term effect is still difficult to evaluate”.
What is certain is that “GERD has a considerable impact on a person’s rest, sleep, diet and social activities, and abroad it is considered a disease with equal harm to diabetes and heart disease.” Xie Pengyan said he is concerned that there are still a large number of patients who have so far gone undetected or misdiagnosed as other diseases.