MEDICAL MYSTERY FOR CHAPTER 8
 

HIS STORY:

For months, Michael was having trouble swallowing, and he often felt as if he had a lump in his throat. His voice sounded hoarse, and he had a dry cough, which he attributed to smoking. Even more troubling, Michael was plagued by mild chest pain. He was especially worried because his dad died of heart disease. Michael managed a retail store, and on the nights when he worked late, he often ate dinner right before bed. This led to indigestion and insomnia. Taking antacids usually helped his stomach and the pyrosisbut not the pain in his chest. One night, the pain was especially severe; though it eased a short time after it started, he was still having trouble swallowing. Concerned, Michael went to see his physicians assistant the next week. Because of Michaels concern about his heart, his PA ordered an electrocardiogram (EKG). When the results turned out to be normal, Michael wondered if his symptomsespecially the trouble swallowingmight be due to a gastrointestinal problem. His PA agreed and gave him a referral to our clinic.

THE EVALUATION:

In taking Michaels medical history, I learned that he had an irregular eating schedule. I asked about his diet, and Michael told me that he had a passion for chocolate, spicy foods, and coffee. I performed a physical exam and did not find any abnormalities. Because Michael reported having trouble swallowing, I wanted to make sure that there was no serious damage to his esophagus from his digestive problems. I had him undergo an esophagogastroduodenoscopy, a test that involves being sedated while an endoscope is inserted into the mouth and down the stomach. The endoscope allowed me to check for a hiatal hernia. Hiatal hernias can also cause reflux and pyrosis.

THE DIAGNOSIS:

Based on Michaels description of his symptoms, I suspected that he had gastroesophageal reflux disease (GERD), which occurs when the lower esophageal sphincter at the bottom of esophagus relaxes, allowing stomach acid to leak back into the esophagus. Over time, the stomach acid can irritate and damage the delicate lining of the esophagus. Fortunately, he did not have any significant buildup of scar tissue (in some GERD sufferers, scar tissue builds up in the esophagus, which can lead to blockages as well as cancer-causing tumors). Michael also did not have a hiatal hernia. What he had was a classic case of GERD.
 

Although most people with GERD suffer from frequent pyrosis, some do not. Some patients have chest pain, a lump in the throat, a cough, or hoarsenesswhich is exactly what Michael had described. Most patients can be diagnosed with GERD based on symptoms alone: iIf they respond to treatment, then the diagnosis is confirmed.

THE TREATMENT 
In order to ease his symptoms and prevent future damage, I prescribed a proton pump inhibitor (PPI) drug, which reduces the acid that is secreted in the stomach. I explained to Michael that medication was just part of the equation: He also had to make lifestyle changes. I urged Michael to limit his intake of coffee, chocolate, and fried or spicy foods, all of which can stimulate acid production in the stomach. In addition, he had to lose weight and stop smoking. GERD occurs when stomach acid leaks back into the esophagus, and smoking weakens the sphincter that separates the esophagus from the stomach. Excess weight puts pressure on the stomach, which may cause acid to back up into the esophagus. Finally, I advised him to eat smaller meals. Not only would eating smaller meals help him lose weight, but it would also prevent his stomach from becoming too full, which puts pressure on the lower esophageal sphincter and increases the chance that the food will reflux.

CASE CLOSED:

Over the next 3 months, Michael lost 8 pounds. He was taking his medication, and he had cut back his coffee consumption to one cup per day. Although he could not resist chocolate and Mexican cuisine, Michael started viewing these foods as occasional treats. He recently started a smoking cessation program at the local hospital. As a result, his chest pain had virtually disappeared, and he was no longer having trouble swallowing. His voice even sounded less hoarse. Now that his symptoms have eased, I was certain that I had diagnosed him correctly.

Discussion Questions

1. The esophagus is a muscular tube through which ingested food passes from the pharynx to the stomach. It is aided in this action by gravity and peristalsis. What is peristalsis?

2. GERD is an abbreviation for gastroesophageal reflux disease. Define the word parts that make up the word gastroesophageal.

3. The doctor decides that Michael does not have a hiatal hernia. What is this?  What are they symptoms of a hiatal hernia?

4. Michael underwent an endoscopy of his esophagus and stomach. Name two lower gastrointestinal system procedures that involve an endoscope, and describe why they are done.