Posted: July 2nd, 2024

Gastroesophageal Reflux Disease: Pathophysiological Case Study

Gastroesophageal Reflux Disease: Pathophysiological Case Study

Gastroesophageal reflux disease (GERD) is a chronic condition affecting the upper gastrointestinal tract, characterised by the reflux of stomach contents into the oesophagus. This case study examines a 75-year-old male patient presenting with worsening GERD symptoms and explores the clinical manifestations, contributing factors, and treatment options.

Clinical Presentation and Symptom Analysis

The patient’s chief complaints include worsening acid reflux, post-prandial burning pain in the chest, and dysphagia. These symptoms, along with regurgitation and nocturnal awakenings, indicate a significant deterioration in the patient’s condition (Gyawali et al., 2018). The presence of dysphagia, a sensation of food becoming stuck behind the breastbone, is particularly concerning as it suggests possible complications such as oesophageal stricture or severe inflammation.

The patient’s symptoms can be classified as classic GERD presentations. The burning sensation in the chest (heartburn), regurgitation, and worsening of symptoms at night are typical manifestations of GERD. The severity of the condition is further evidenced by the ineffectiveness of the current histamine-2 receptor blocker therapy and the need for additional antacid use (Maret-Ouda et al., 2020).

Contributing Factors

Several factors potentially contribute to the exacerbation of this patient’s GERD symptoms:

1. Lifestyle factors: High caffeine intake (5 cups of coffee per day), alcohol consumption, and smoking are known to aggravate GERD symptoms by reducing lower oesophageal sphincter pressure and increasing gastric acid production.

2. Medical history: The presence of a hiatal hernia and alcoholic cirrhosis can contribute to GERD by altering the anatomy of the gastroesophageal junction and affecting oesophageal motility.

3. Medications: Verapamil, a calcium channel blocker used for hypertension management, may exacerbate GERD symptoms by reducing lower oesophageal sphincter tone (Hunt et al., 2019).

4. Dietary habits: While not explicitly mentioned, the patient’s enjoyment of gourmet dining may involve consumption of fatty or spicy foods, which are known GERD triggers.

5. Body weight: The patient’s weight (195 lbs) and height (58 inches) suggest obesity, a significant risk factor for GERD.

Management Strategies

Non-pharmacological interventions and lifestyle modifications should be the first line of approach in managing this patient’s GERD:

1. Dietary modifications: Limiting caffeine, alcohol, and acidic foods; avoiding large meals close to bedtime.

2. Weight loss: Implementing a structured weight loss program to reduce abdominal pressure.

3. Smoking cessation: Enrolling in a smoking cessation program to eliminate this significant GERD trigger.

4. Elevation of the head of the bed: Recommending elevation by 6-8 inches to reduce nocturnal reflux.

5. Stress management: Introducing relaxation techniques or counselling if stress is a contributing factor.

Pharmacotherapeutic options for this patient include:

1. Proton pump inhibitors (PPIs): Considering the inadequacy of H2 receptor antagonists, a trial of PPIs such as omeprazole or esomeprazole may be warranted.

2. Prokinetic agents: Medications like metoclopramide might be considered to improve gastric emptying and lower oesophageal sphincter pressure.

3. Alginates: These can be used as adjunct therapy to provide a protective barrier against reflux.

The choice of therapy should be based on the severity of symptoms, potential drug interactions, and patient preferences (Savarino et al., 2022).

Clinical Course and Further Management

Upper endoscopy revealed multiple, circular, confluent erosions of the distal oesophagus, consistent with Grade C esophagitis according to the Los Angeles Classification system. The absence of Barrett’s oesophagus or strictures is reassuring but necessitates close monitoring.

The initial response to lansoprazole therapy was positive, with resolution of both heartburn and dysphagia. However, the recurrence of symptoms after discontinuation of PPI therapy suggests the need for long-term management strategies.

Therapeutic options at this stage include:

1. Maintenance PPI therapy: Considering long-term, possibly lifelong, PPI therapy at the lowest effective dose.

2. Step-down approach: Gradually reducing PPI dose or switching to on-demand therapy.

3. Surgical intervention: Evaluating the patient’s suitability for anti-reflux surgery, such as laparoscopic fundoplication, particularly if long-term PPI therapy is undesirable or ineffective.

4. Endoscopic therapies: Exploring minimally invasive endoscopic procedures like the LINX device or transoral incisionless fundoplication as alternatives to traditional surgery (Repici et al., 2023).

The management plan should be tailored to the patient’s overall health status, considering his age and comorbidities. Regular follow-up and periodic endoscopic surveillance are essential to monitor for potential complications and ensure optimal symptom control.

References

Gyawali, C.P., Kahrilas, P.J., Savarino, E., Zerbib, F., Mion, F., Smout, A.J., Vaezi, M., Sifrim, D., Fox, M.R., Vela, M.F. and Tutuian, R., 2018. Modern diagnosis of GERD: the Lyon Consensus. Gut, 67(7), pp.1351-1362.

Hunt, R., Armstrong, D., Katelaris, P., Afihene, M., Bane, A., Bhatia, S., Chen, M.H., Choi, M.G., Melo, A.C., Fock, K.M. and Ford, A., 2019. World gastroenterology organisation global guidelines: GERD global perspective on gastroesophageal reflux disease. Journal of clinical gastroenterology, 53(5), pp.329-338.

Maret-Ouda, J., Markar, S.R. and Lagergren, J., 2020. Gastroesophageal reflux disease: a review. Jama, 324(24), pp.2536-2547.

Repici, A., Schwaitzberg, S.D., Bapaye, A., Bhat, Y.M., Costamagna, G., Kozarek, R.A., Patil, G., Perretta, S., Ponchon, T. and Swanström, L.L., 2023. Endoluminal and surgical treatments for gastroesophageal reflux disease. Nursing writing services Nature Reviews Gastroenterology & Hepatology, 20(1), pp.31-46.

Savarino, E., Bredenoord, A.J., Fox, M., Pandolfino, J.E., Roman, S. and Gyawali, C.P., 2022. Advances in the physiological assessment and diagnosis of GERD. Nature Reviews Gastroenterology & Hepatology, 19(3), pp.152-168.

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PATIENT CASE
Patient’s Chief Complaints
“My acid reflux is getting worse and my histamine blocker isn’t working anymore. About an hour after a meal, I get a burning pain in the middle of my chest. Sometimes, I have trouble getting food down. It seems to get stuck behind my breastbone. I’ve never had that problem before. My heartburn is affecting my quality of life again and I want it to stop.”
HPI
W.R. is a 75 yo male with a significant history of GERD. He presents to the family practice clinic today for a routine follow-up visit. The patient reports that during the past three weeks he has experienced increasing episodes of post-prandial heartburn with some regurgitation and dysphagia. He has also begun using antacids daily in addition to histamine-2-receptor blockers for symptom relief. Despite sleeping with three pillows, the patient has also begun
to experience frequent nocturnal awakenings from heartburn and regurgitation.
PMH
• HTN
15 years
• GERD
7 years
• Alcoholic cirrhosis
2 years
• Hiatal hernia
FH
Non-contributory
SH
• Patient is widowed and lives alone; daughter lives in same town, checks on him regularly, and takes him grocery shopping every Saturday
CASE STUDY
GASTROESOPHAGEAL 25 REFLUX DISEASE
For the Disease Summary for this case study,
see the CD-ROM.

CASE STUDY GASTROESOPHAGEAL REFLUX DISEASE
• Patient is a retired college basketball coach
• Enjoys cooking, traveling, gourmet dining, and playing poker
• () caffeine; 5 cups coffee/day
• () EtOH; history of heavy alcohol use; current EtOH consumption reported is 6 beers
with shots/week
• () smoking; 55 pack-year history; currently smokes 3
⁄4 ppd
Meds
• Verapamil SR 120 mg po QD
• Hydrochlorothiazide 25 mg po QD
• Famotidine 20 mg po Q HS
All
• Citrus fruits and juices (upset stomach)
• Dogs (itchy eyes, runny nose, sneezing)
• Erythromycin (unknown symptoms)
ROS
• () H/A, dizziness, recent visual changes, tinnitus, vertigo
• () SOB, wheezing, cough, PND
• () frequent episodes of burning, non-radiating substernal CP
• () dysphagia
• () sore throat or hoarseness
• () N/V, diarrhea, BRBPR or dark/tarry stools
• () recent weight change
PE and Lab Tests
Gen
The patient is a pleasant, talkative Native American man who is wearing a sports jacket, jeans, and tennis shoes. He looks his stated age and does not appear to be in distress.
VS
See Patient Case Table 25.1
Patient Case Table 25.1 Vital Signs
BP 155/90 RR 18 and unlabored HT 58
P 75 and regular T 97.9°F WT 195 lbs
Skin
No rashes or lesions noted
HEENT
• PERRLA
• EOMI
Bruyere_Ca
118 PART 3 ■ GASTROINTESTINAL DISORDERS
• () arteriolar narrowing and A-V nicking
• Pink, moist mucous membranes
• () tonsils
• Oropharynx clear
Lungs
CTA
Heart
• Regular rhythm
• () additional heart sounds
Abd
• Normoactive BS
• Soft, NT/ND
• () HSM
• () bruits
Genit/Rec
• () hemorrhoids
• () rectal masses
• Brown stool without occult blood
• Prostate WNL
Ext
() CCE
Neuro
• A & O for person, time, place
• CNs II–XII intact
• Strength 5/5 upper/lower extremities bilaterally
Patient Case Question 1. Which clinical information suggests worsening symptoms of GERD in this patient?
Patient Case Question 2. Which symptom(s) indicates the possible severity of the
patient’s GERD?
Patient Case Question 3. Are the patient’s symptoms classic or atypical?
Patient Case Question 4. Identify all those factors that may be contributing to the patient’s symptoms.
Patient Case Question 5. Why is the drug verapamil a potential contributing factor to the patient’s symptoms?
Patient Case Question 6. What non-pharmacologic therapies or lifestyle modifications might be beneficial in the management of this patient’s acid reflux disease?
Patient Case Question 7. What pharmacotherapeutic alternatives are available for the treatment of this patient’s GERD?

Clinical Course
The patient underwent upper endoscopy, which revealed multiple, circular, confluent erosions of the distal esophagus. There was no evidence of bleeding, ulcerations, stricture, or esophageal metaplasia. The patient was treated with an 8-week course of 30 mg/day lansoprazole and both heartburn and dysphagia resolved. Approximately 10 weeks after PPI therapy was discontinued, the patient reported that his reflux symptoms had returned and that he was again suffering from frequent post-prandial and nocturnal episodes of reflux.
Patient Case Question 8. What therapeutic options are now available for this patient?
Patient Case Question 9. Based on upper endoscopy test results, what grade of
esophagitis can be assigned to this patient’s condition?

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Tags: My acid reflux is getting worse and my histamine blocker isn’t working anymore, W.R. is a 75 yo male with a significant history of GERD