Mrs T is a 45 yr old female who reports frequent heartburn and regurgitation of acid into her mouth for the past 3 months. There is no change in her usual eating habits, or in her weight. She has no problem with swallowing, food getting stuck, or respiratory issues. There is no abdominal pain. She has tried taking over the counter antacids, such as calcium carbonate (Tums), with only a little relief.
Introduction
Gastroesophageal reflux disease (GERD) is a common chronic digestive disorder characterized by the backflow of stomach acid into the esophagus. It is estimated that GERD affects approximately 10-20% of the population in Western countries (El-Serag, 2014).
Case Presentation
In this case, Mrs T, a 45-year-old female, presents with frequent heartburn and regurgitation of acid into her mouth for the past three months. There have been no changes in her usual eating habits or weight. Mrs T does not report any difficulty swallowing, food getting stuck, or respiratory issues. Additionally, she does not experience abdominal pain. Despite trying over-the-counter antacids, such as calcium carbonate (Tums), Mrs T has only found temporary relief.
In order to formulate an appropriate management plan for Mrs T, it is important to consider the underlying pathophysiology of GERD, possible causes of her symptoms, and diagnostic strategies to confirm the diagnosis.
Pathophysiology of GERD
GERD occurs when there is a dysfunction of the lower esophageal sphincter (LES), which normally prevents the backflow of stomach acid into the esophagus. Dysfunction of the LES can occur due to a variety of factors, including alterations in the pressure gradient between the stomach and esophagus, impaired clearance of acid from the esophagus, or impairment of esophageal defense mechanisms (Kahrilas & Bredenoord, 2014).
The reflux of stomach acid into the esophagus leads to the classic symptoms of GERD, such as heartburn and regurgitation. Prolonged exposure to gastric acid can result in esophageal mucosal injury and inflammation, leading to complications such as erosive esophagitis, strictures, and Barrett’s esophagus (Kahrilas & Bredenoord, 2014).
Possible Causes of Mrs T’s Symptoms
While GERD is the most likely cause of Mrs T’s symptoms, it is important to consider other potential causes that may mimic or contribute to her presenting complaints. Some of these include:
1. Hiatal hernia: A hiatal hernia occurs when the upper part of the stomach protrudes into the chest through the diaphragmatic opening. This can lead to impaired LES function and an increased risk of reflux (Lu, 2021). However, hiatal hernias are often asymptomatic and do not necessarily correlate with the severity of symptoms in GERD patients.
2. Peptic ulcer disease: Peptic ulcers are erosions in the lining of the stomach or duodenum, which can cause symptoms similar to those of GERD. However, the absence of abdominal pain in Mrs T makes this less likely.
3. Gastric motility disorders: Disorders of gastric motility can lead to delayed gastric emptying and result in reflux. Conditions such as gastroparesis and functional dyspepsia should be considered in the differential diagnosis.
Diagnostic Strategies for GERD
To confirm the diagnosis of GERD and guide management, several diagnostic strategies can be employed. These include:
1. Symptom evaluation: Mrs T’s symptoms are typical of GERD, with frequent heartburn and regurgitation of acid. However, clinical symptoms alone are not sufficient for a definitive diagnosis, as they may overlap with other gastrointestinal conditions.
2. Trial of proton pump inhibitors (PPIs): PPIs are the most effective therapy for GERD and can provide relief for the majority of patients. A trial of PPI therapy can help determine if the symptoms are indeed due to acid reflux. If symptoms improve with PPIs, it supports the diagnosis of GERD.
3. Esophageal pH monitoring: This diagnostic test measures the frequency and duration of acid exposure in the esophagus over a 24-hour period. It can help confirm the presence of abnormal acid reflux episodes and assess the effectiveness of medical therapy.
4. Upper endoscopy: Also known as esophagogastroduodenoscopy (EGD), this procedure allows direct visualization of the esophagus, stomach, and duodenum. EGD is indicated in patients with alarm symptoms (such as dysphagia, weight loss, or gastrointestinal bleeding) or in those who do not respond to PPI therapy.
Conclusion
Based on Mrs T’s symptoms of frequent heartburn and regurgitation of acid, along with the lack of changes in her eating habits or weight, it is highly likely that she is suffering from GERD. However, further diagnostic investigations may be necessary to confirm the diagnosis and exclude other potential causes.