Reflux in a 35-year-old man

Problem 11 Reflux in a 35-year-old man



Chris Deans, Andrew C. DeBeaux




A 35-year-old man presents with symptoms of epigastric bloating and heartburn. He also describes a retrosternal burning sensation, particularly at night, which may wake him from sleep. He has experienced ‘stomach’ symptoms for most of his adult life and has used over-the-counter antacids periodically with some relief. In the past few months his symptoms have become more frequent. His job has become more stressful recently, and he thinks the increased stress is related to his worsening symptoms. His symptoms have now reached a level that has made him report to his general practitioner.

He has no other past medical history and takes no regular medications. He smokes between 5 and 10 cigarettes per day and only drinks alcohol at the weekend, when he often drinks in excess of 10 pints of beer. He is overweight with a body mass index (BMI) of 32. His general examination is otherwise normal.



Q.1


What is the most likely diagnosis and what is your initial management plan?


The patient is given some counselling on lifestyle measures and encouraged to use over-the-counter medications as required. He returns for a follow-up visit 3 months later. He has stopped smoking and has reduced his alcohol intake. He has also managed to lose 5 kg in weight. He feels healthier than ever before but many of his dyspeptic symptoms persist.



Q.2


What is your next management plan? Which investigations might you request?



Q.3


Which pathogen is associated with reflux and dyspepsia symptoms? What investigations are available to test for it?


You adopt a ‘test and treat’ management strategy. You refer the patient for a breath test which comes back positive. You prescribe a 10 day course of triple therapy (esomeprazole, amoxicillin and metronidazole) and arrange to see him back for review in 6 weeks. At his review you find that after an initial improvement his symptoms have recurred in the preceding week.



Q.4


What is the appropriate management plan for the patient?


A repeat breath test is positive and the patient is given a further course of triple therapy which gives him good symptomatic relief. Two years later the patient returns. His dyspepsia-type symptoms have settled, but his main complaint now is heartburn. Also, when he bends over he can reflux gastric content into his mouth, making him cough. Six months previously he was started on pantoprazole but every time he stops the medication his symptoms worsen. He does not like the idea of taking tablets long term and wishes to discuss other treatment options. He has heard about endoscopic methods for ‘fixing the valve’.



Q.5


What treatment options would you discuss with this patient?


The patient has already tried increasing the dosage of his PPI, but to no effect.



Q.6


What investigations might you consider performing before undertaking surgery?


Your patient decides not to opt for surgery and he continues on his PPI therapy. A few years later he returns. Despite deciding to continue on medical therapy his compliance with acid suppression has been poor. For the past few months his reflux symptoms have worsened and he had been feeling increasingly tired. You think he looks pale and you perform some blood tests.


His haemoglobin is 102 g/L, white cell count 6.7 × 109/L, platelet count 275 × 109/L and mean cell volume 72 fL.



Q.7


What do these blood tests reveal and what do they suggest?


You are concerned by his anaemia and arrange for him to undergo an urgent upper GI endoscopy. (Remember, in iron deficient anaemia, if the upper GI endoscopy is normal, a colonoscopy may be indicated.) The view in Figure 11.1 shows the lower oesophagus.


image

Figure 11.1



Q.8


What is the pathological condition seen at endoscopy and what should be done?


Biopsies are reported as showing Barrett’s metaplasia with features of high-grade dysplasia. There are no features of malignancy on the samples analysed. You commence the patient on high-dose PPI and reinforce the importance of compliance. Another endoscopy is arranged for 6 weeks’ time with repeat biopsies.


Despite good compliance with drug therapy, the repeat endoscopy identifies a small area of raised Barrett’s mucosa which is biopsied, along with multiple other sites. These repeat biopsies now show low-grade dysplasia, except for the biopsies from the raised area, which identify localized high-grade dysplasia with features of carcinoma in situ.



Q.9


What is your next management strategy?


Endoscopic ultrasound confirms a small nodular area which is staged as T1 disease at most. No other mucosal abnormality is identified and the surrounding lymph nodes are not suspicious of metastatic disease. The staging CT scan is reported as normal.



Q.10


How would you further manage this patient?


Your patient is treated by endoscopic mucosal resection (EMR) and the abnormal area is completely excised. He will need to continue on lifelong PPI therapy and he will need regular endoscopic surveillance to monitor his Barrett’s segment.



Answers


A.1 Dyspepsia or reflux disease.


• Dyspepsia is a term often used for many upper gastrointestinal symptoms such as epigastric discomfort and heartburn and is poorly defined. Some pathological conditions may be found as the cause of these symptoms, but in many cases no abnormality is identified and the condition is described as functional dyspepsia.

• Reflux disease, more correctly termed gastro-oesophageal reflux disease (GORD), is the reflux of gastric contents back into the oesophagus.

Patients with alarm symptoms, such as weight loss, recurrent vomiting, anaemia or dysphagia, should be referred for urgent investigation by upper gastrointestinal endoscopy. For most patients with uncomplicated dyspepsia the initial management is aimed at symptomatic treatment. Initially, general lifestyle changes are recommended, including smoking cessation, weight loss, minimizing alcohol and caffeine intake, reducing food intake before going to bed, and sleeping with the head of the bed raised. Over-the-counter antacid preparations and mucosal protecting agents may also provide some symptomatic relief. These measures alone may be sufficient to provide symptomatic control.


A.2 Patients with persistent symptoms require further evaluation. Patients older than 50 years should be considered for referral for an upper gastrointestinal endoscopy as the risk of an underlying malignancy is higher in this age group. For younger patients without alarm symptoms, an endoscopy is probably not indicated at this stage. A trial of acid suppression therapy may be advised. Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists are widely used worldwide with a good safety profile, although the effects of long-term use are still not fully determined. Prokinetic agents, such as metoclopramide, may be also used to aid gastric emptying particularly when associated with gastro-oesophageal reflux.


A.3 Helicobacter pylori (H. pylori) is a Gram-negative bacillus that favours the conditions found within the gastric antrum. The organism promotes acid hypersecretion within the stomach and induces gastric inflammation and has been associated with dyspepsia and reflux symptoms.


Several methods have been developed to test for the presence of H. pylori.


• Serology is the least useful test as a positive result denotes only previous exposure and does not necessarily indicate a current or active infection.

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Reflux in a 35-year-old man

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