Case Study 7

1 to 7, 9, 10, 12, 13, and 17

1. Gastric acid is mad in the parietal cells which are a type of cells in the stomach. The secretion
itself has many different components such as pepsinogen which is converted by HCL to create
active pepsin (stomach enzyme). It is controlled by the neural and hormonal mechanisms of the
body.

2. The main job of the LES is to provide a barrier between the esophagus and stomach to
prevent the reflux of gastric contents. In order for reflux to happen, the proximal stomach
pressure must be greater than the pressure in the esophagus. Things that can affect LES
pressure are secretions of gastrin, estrogen, or progesterone, as well as lifestyle factors such as
smoking and ingestion of certain “trigger” foods.

3. Some complications of gastrointestinal reflux are severe pain in the neck, back, and/or jaw,
as well as a potential for swallowing difficulty due to esophageal scar tissue. Prolonged
nontreatment of GERD could lead to ulcers, esophageal scarring/erosion, possibly esophageal
cancer, and even irreversible damage to the throat and lungs.

4. H. pylori is short for helicobacter pylori, a gram-negative bacteria that can survive in the
highly acidic environment of the stomach. Most physicians ask for a biopsy of this particular
bacteria because it can be the cause of many cases of chronic inflammation in the gastric
mucosa, such as peptic ulcers, gastric cancer, and atrophic gastritis (chronic inflammation with
deterioration of mucous membranes and glands). Symptoms of a H. pylori infection are quite
similar to symptoms of GERD, so the physician wanted to rule out the possibility of a H. pylori
infection so his treatment plan could be targeted at the treatment of GERD.

5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease. The patient’s signs and symptoms that could suggest a
diagnosis of gastroesophageal reflux disease are as follows:
1) The MD’s progress note states that during his review of systems, the gastrointestinal
system had a heme + stool review (meaning, blood in the stool).
2) The patient has reported indigestion only at night but has recently felt indigestion
daily/constantly. He takes Tums every day to help relieve these symptoms.

6. The diagnostic tests performed for this patient are the following:
- Chem 24 test: this test is a metabolic panel that tests for 24 different compounds,
including Albumin, Blood Urea Nitrogen, cholesterol, HDL, LDL, sodium, potassium,
triglycerides, uric acid, and many more. While this test is very comprehensive, other tests need
to be done to accurately and completely diagnose Mr. Gupta.
- Ambulatory 48-hour pH monitoring: in this test, Mr. Gupta swallows a small, pilllike
capsule that attaches itself to the inside of the esophagus when swallowed. For 48 hours, it
records the pH of the interior of the esophagus and transmits the message to a receiver the
patient carries around on his or her belt.
- Barium esophagram: this is a test in which Mr. Gupta swallows liquid barium sulfate, a
metallic compound that can show up on x-rays and help radiologists see any abnormalities in
the esophagus, such as tears, ulcers, cysts, etc.
- Endoscopy with biopsy to r/o H. pylori: An endoscopy of the stomach with a biopsy
(examination of living tissue) is being ordered to rule out H. pylori because an infection caused
by this bacterium can cause symptoms similar to GERD. The MD wants to rule out an infection
that could be treated by an antibiotic rather than prescribe a medication that would be
ineffective and not fix the cause of the symptoms.

7. What risk factors does the patient present with that might contribute to his diagnosis? (Be
sure to consider lifestyle, medical, and nutritional factors.) The patient presents several risk
factors that could contribute to his diagnosis of GERD.
• Class I Obesity with a BMI of 32.
• Unhealthy diet patterns with an overconsumption of high fat foods and sugary drinks
• Rapid weight gain (30 lbs within 3 years)
• Decreased physical activity
• Diagnosis of hypertension
• Family history of Coronary Heart Disease (CHD) on father’s side
• Increased frequency of drinking alcohol
• Increased stress with long work hours and a busy lifestyle
• 500 mg ibuprofen x2 / day
• 325 mg aspirin x1 /day
• Age of 48 years

9. It is a categorized acid blocker that is functions as a proton-pump inhibitor- essentially

stopping the production of stomach acid completely. This is done by preventing the proton-
pumps that produce stomach acid from producing it, through the blockage of the pumps by
PPIs, inhibiting the final step of acid production. Other drugs in this class are pantoprazole,
esomeprazole and lansoprazole. Other groups of medications used for GERD are antacids and
H2 blockers. An example would be the commercial drug, Tums!

10. The goal right now is lower the amount of acidic/gastric contents that comes into contact
with the esophageal space. It is also to lower the amount of acidic secretion and overall
decrease pain and discomfort. Some of the nutritional recommendations are the following:
- don’t eat large meals
- avoid caffeinated drinks
- no spicy foods
- lose weight if overweight
- after a meal, don’t lay down or wear tight clothes
- eat within 3-4 hours of going to bed
12. *Work done on separate sheet*

He requires around 1720 kcals of energy

He requires about 98 g of protein
He requires about 15 cups of fluid

To support his gradual weight loss, he should do the following:

- He should eat about 100-200 kcal less than what he needs for energy
- Eat less calorie dense foods! Replace some foods with something with lower calorie
foods so you can keep the same food volume
- Instead of having 2 pieces of bread, replace one slide with a fruit or veggie
- Same with the rice ^ replace a cup with veggies. Baby steps.

13. Coming from that culture, foods are seasoned to be very spicy. That is what really triggers
his GERD. The foods are also sour, high in fat, minty, and are caffeinated. An example of a
traditional dish is curry, which is spicy stew and rice. Exactly what he should not be eating!

17. Both are used as methods to quell GERD. The first, fenugreek, can reduce heartburn but the
evidence isn’t monumental. Turmeric is used for pain mostly, and sometimes to quell H.pylori,
peptic ulcers, IBS and other inflammatory conditions. There is not strong evidence for its work
towards dyspepsia and H.pylori. I could tell Mr. Gupta that the herbs are safe to take and would
make him feel slightly better but the supplement is not the best options for dealing with the
real issue. But if he was to be prescribed a blood thinner, he should not use turmeric! He should
monitor all meds and their contradictions to the herbs.