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Posted: August 7th, 2023

Esophageal Reflux: A Diagnostic Case Study

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Esophageal Reflux
Case Studies
A 45-year-old woman complained of heartburn and frequent regurgitation of “sour” material into
her mouth. Often while sleeping, she would be awakened by a severe cough. The results of her
physical examination were negative.
Studies Results
Routine laboratory studies Negative
Barium swallow (BS), p. 941 Hiatal hernia
Esophageal function studies (EFS), p. 624
Lower esophageal sphincter (LES)
4 mm Hg (normal: 10–20 mm Hg)
Acid reflux Positive in all positions (normal: negative)
Acid clearing Cleared to pH 5 after 20 swallows (normal:
<10 swallows)
Swallowing waves Normal amplitude and normal progression
Bernstein test Positive for pain (normal: negative)
Esophagogastroduodenoscopy (EGD), p. 547 Reddened, hyperemic, esophageal mucosa
Gastric scan, p. 743 Reflux of gastric contents to the lungs
Swallowing function, p. 1014 No aspiration during swallowing
Diagnostic Analysis
The barium swallow indicated a hiatal hernia. Although many patients with a hiatal hernia have
no reflux, this patient’s symptoms of reflux necessitated esophageal function studies. She was
found to have a hypotensive LES pressure along with severe acid reflux into her esophagus. The
abnormal acid clearing and the positive Bernstein test result indicated esophagitis caused by
severe reflux. The esophagitis was directly visualized during esophagoscopy. Her coughing and
shortness of breath at night were caused by aspiration of gastric contents while sleeping. This
was demonstrated by the gastric nuclear scan. When awake, she did not aspirate, as evident
during the swallowing function study. The patient was prescribed esomeprazole (Nexium). She
was told to avoid the use of tobacco and caffeine. Her diet was limited to small, frequent, bland
feedings. She was instructed to sleep with the head of her bed elevated at night. Because she had
only minimal relief of her symptoms after 6 weeks of medical management, she underwent a
laparoscopic surgical antireflux procedure. She had no further symptoms.
Critical Thinking Questions
1. Why would the patient be instructed to avoid tobacco and caffeine?
2. Why did the physician recommend 6 weeks of medical management?
Case Studies
Copyright © 2018 by Elsevier Inc. All rights reserved.
3. How do antacid medication work in patients with gastroesophageal reflux?
4. What would you approach the situation, if your patient decided not to take the medication
and asked you for an alternative medicine approach?

Esophageal Reflux: A Diagnostic Case Study

Esophageal reflux, commonly known as gastroesophageal reflux disease (GERD), is a chronic condition characterized by the backflow of stomach contents into the esophagus. This case study involves a 45-year-old woman who presented with heartburn, regurgitation of sour material, and nighttime cough, suggestive of GERD. In this analysis, we will discuss the diagnostic process, treatment options, and critical thinking questions related to the management of the patient.

Diagnostic Findings
Upon physical examination, the patient showed no significant abnormalities. However, the results of the diagnostic tests revealed important insights. The barium swallow indicated the presence of a hiatal hernia, which alone may not always cause reflux symptoms. To further investigate the severity of the reflux, esophageal function studies were conducted, which showed a hypotensive lower esophageal sphincter (LES) pressure (4 mm Hg, normal: 10–20 mm Hg) and positive acid reflux in all positions (normal: negative). Additionally, the acid clearing test exhibited delayed clearance to pH 5 after 20 swallows (normal: <10 swallows), and the Bernstein test was positive for pain (normal: negative). These findings pointed towards esophagitis caused by severe reflux. Esophagoscopy directly visualized the red, hyperemic esophageal mucosa.

Further investigations using a gastric scan demonstrated reflux of gastric contents into the lungs, explaining the patient’s nighttime cough and shortness of breath due to aspiration while sleeping. However, it was reassuring to find no aspiration during swallowing while awake, as observed in the swallowing function study.

Diagnostic Analysis
The patient’s hiatal hernia combined with the hypotensive LES pressure and severe acid reflux resulted in esophagitis, which explained her symptoms of heartburn, regurgitation, and nighttime cough. The gastroesophageal reflux causing aspiration during sleep was confirmed by the gastric scan, highlighting the importance of investigating the extent of GERD.

Treatment Plan and Outcomes
Based on the diagnosis, the patient was prescribed esomeprazole (Nexium), a proton pump inhibitor (PPI) known for its effectiveness in reducing gastric acid secretion. Additionally, she was advised to avoid tobacco and caffeine. The rationale behind this recommendation lies in the fact that tobacco and caffeine can relax the LES, exacerbating reflux symptoms.

To address the patient’s lifestyle and eating habits, she was instructed to adopt small, frequent, bland feedings, and elevate the head of her bed while sleeping. These measures aimed to minimize reflux events and improve overall symptom relief. However, after six weeks of medical management with esomeprazole, the patient experienced only minimal relief, necessitating further intervention.

Due to the inadequate response to medical therapy, the patient underwent a laparoscopic surgical antireflux procedure. This surgical approach is often considered for patients with persistent GERD symptoms despite medication. Fortunately, the surgical procedure provided complete symptom resolution, indicating its efficacy in managing severe GERD cases.

Critical Thinking Questions

Avoidance of tobacco and caffeine: The patient was instructed to avoid tobacco and caffeine as they can relax the LES, leading to increased reflux. Caffeine is known to reduce LES pressure, and tobacco can interfere with the normal esophageal motility, both of which may exacerbate reflux symptoms.

6 weeks of medical management: The physician recommended 6 weeks of medical management with esomeprazole to assess the patient’s response to PPI therapy. This duration allows sufficient time to gauge the effectiveness of the medication in controlling acid reflux and alleviating symptoms before considering alternative treatment options.

Mechanism of antacid medication in GERD patients: Antacid medications, particularly proton pump inhibitors like esomeprazole, work by inhibiting the H+/K+ ATPase enzyme in the gastric parietal cells. This enzyme plays a crucial role in the production of hydrochloric acid in the stomach. By blocking this enzyme, PPIs reduce the amount of acid secreted, thereby reducing the acidity of gastric contents that reflux into the esophagus. This helps alleviate GERD symptoms and promotes esophageal healing.

Alternative medicine approach: If the patient decided not to take the prescribed medication, it would be essential to explore alternative treatment options. A comprehensive approach may involve lifestyle modifications, such as dietary changes, weight management, and elevating the head of the bed. Additionally, the patient could be advised to try over-the-counter antacids or H2-receptor blockers, which also reduce gastric acid secretion. However, it is crucial to emphasize the potential limitations of alternative treatments and the importance of monitoring symptoms closely to avoid worsening of esophagitis or complications associated with untreated GERD.

The case study of the 45-year-old woman with esophageal reflux highlights the significance of thorough diagnostic evaluation in managing GERD. The combination of hiatal hernia, hypotensive LES pressure, and severe acid reflux led to esophagitis, resulting in troubling symptoms like heartburn, regurgitation, and nighttime cough. The patient’s response to medical management was insufficient, necessitating surgical intervention, which provided complete symptom resolution. Understanding the mechanisms of GERD and tailoring treatment based on individual patient needs are vital for achieving optimal outcomes in managing this condition.


Lewis, J. S. (Ed.). (2018). Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition.
Velanovich, V. (2016). The Barrett’s Esophagus: What’s the Current State of Play? Journal of Gastrointestinal Surgery, 20(2), 419-428.
Kahrilas, P. J., & Pandolfino, J. E. (2016). New Technologies in the Management of Gastroesophageal Reflux Disease. Journal of Neurogastroenterology and Motility, 22(3), 360-370.
Richter, J. E. (2017). Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication. Clinical Gastroenterology and Hepatology, 15(5), 665-676.

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