Case Study: You are in the middle of your clinic day, when you note that your next patient is here to follow-up for recurrent gastroesophageal reflux disease (GERD). Ben is a 55-year-old man with a current history of obesity and cigarette smoking. When you walk into the exam room, he greets you with the following words: “The heartburn just keeps getting worse. I can’t eat anything anymore without it wrecking my day.”
You tell him you are sorry to hear it, and ask him to tell you more about his symptoms. Ben tells you that a few months ago he would have heartburn once or twice a week. Now he is having very uncomfortable, burning chest pain half an hour after eating lunch and dinner most days of the week. He takes Tums by the handful, but it only helps a little bit. He also has a brackish aftertaste, though it does not bother him as much as the reflux pain. He denies any nausea or vomiting, weight gain or weight loss, fever, cough, severe or radiating chest pain, or changes in his bowel movements. He used to smoke one and a half packs per day but has now decreased his smoking to one pack per day because he thinks smoking makes his reflux worse. He also recently had a chest x-ray after a bout of bronchitis that was normal. On physical exam he is afebrile, has a heart rate of 70 beats per minute, respiratory rate of 18, and blood pressure of 135/82. He is overweight with a BMI of 33 kg/m2. On physical exam, Ben’s heart rate has a regular rate and rhythm, his breath sounds are clear, and his abdomen is soft and non-tender to palpation.
What do you want to do now?
You ask him if he has done anything to manage his symptoms other than Tums. He tells you that he takes an over-the-counter medication while eating if he eats anything “greasy” or “fatty” at home. However, he often eats out and finds that his symptoms are most severe when he does not have any of his medication readily available. When you ask him what specific meals trigger his heartburn, he gives you a list of the usual suspects: spicy foods with onions and tomato sauce, alcohol, diet and regular soda, and chocolate desserts. He also has worse reflux after smoking.
What sort of lifestyle and medical management would you recommend for Ben?
Looking at this problem holistically, you decide against giving a long list of specific food restrictions to the patient. Instead, you tell him that you have short-term and long-term management plans for how he can treat his GERD. In the short term, he can start taking a proton-pump inhibitor (PPI) more strategically and effectively. Both over-the-counter and prescribed PPIs should be taken half an hour before eating a meal that has a high likelihood of causing reflux. Since he has been having moderate to severe reflux lately, he can try taking the PPI regularly for a few months. If it improves or he has only mild reflux, he can take a PPI on a case-by-case basis instead of regularly. In the long-term, you recommend that he lose weight, stop smoking, improve his sleep quality, decrease his dietary fat and increase his dietary protein intake, and start an exercise program.
The actions that will make the most difference will probably be weight loss and smoking cessation. If his reflux does not improve with regularly taking a PPI, you will refer him to a gastroenterologist to undergo an upper endoscopy to look for signs of esophageal damage. Surgical interventions, such as Nissen fundoplications are becoming less common as a result of the effectiveness of PPIs.
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1383-1391, 1391.e1-5.
Sandhu DS, Fass R. Current Trends in the Management of Gastroesophageal Reflux Disease. Gut Liver. 2018;12(1):7-16.
Dr. V. Silverstein
Published on 7/20/19