Patient Is A 21-Year-Old Male With GERD Without Esophagitis

Patient Is A 21 Yo Male With Gerd Without Esophagitis Who Came To Di

Patient is a 21-year-old male diagnosed with gastroesophageal reflux disease (GERD) without evidence of esophagitis. The patient presented for discussion of diagnostic test results. An abdominal ultrasound was performed and found to be within normal limits. The patient reports consultation with a gastroenterologist, who ordered a Helicobacter pylori (H. pylori) test, which returned negative. Treatment was initiated with Omeprazole 40 mg taken orally daily and Sucralfate for a duration of three months. The care plan also includes considering endoscopy if symptoms persist or worsen. Lifestyle modifications and dietary changes were recommended, and patient education regarding these adjustments was provided. Follow-up will be scheduled as needed to monitor symptom progression and response to therapy.

The patient reports experiencing a burning sensation in the abdomen frequently after eating, with symptoms sometimes worsening at night or when lying down. These symptoms are characteristic of GERD, which can cause significant discomfort and impact quality of life if not well controlled. The diagnosis is coded as K21.9, indicating gastroesophageal reflux disease without specification of esophagitis.

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Gastroesophageal reflux disease (GERD) is a prevalent condition characterized by the reflux of stomach contents into the esophagus, leading to symptoms such as heartburn and regurgitation (Camilleri, 2018). It significantly impacts patients' quality of life, especially when symptoms are persistent or poorly responsive to initial management strategies. The case of a 21-year-old male with GERD without esophagitis exemplifies the importance of a comprehensive diagnostic and therapeutic approach tailored to individual patient needs.

Clinical Presentation and Diagnostic Evaluation

The patient’s primary complaints include a burning sensation in the abdomen often after eating, which worsens at night or when lying flat. These symptoms are typical of GERD, resulting from the reflux of gastric contents into the esophagus due to lower esophageal sphincter dysfunction (Falk et al., 2019). The initial diagnostic approach often includes a detailed history, physical examination, and non-invasive tests such as abdominal ultrasound to rule out other abdominal pathologies—although ultrasound has limited utility in directly diagnosing GERD (Vanderhaeghen et al., 2017).

The negative H. pylori test indicates that bacterial infection is unlikely to contribute to the patient’s symptoms. H. pylori is often associated with peptic ulcer disease, which can mimic GERD symptoms or coexist with GERD, thus warranting testing in symptomatic patients (Chey et al., 2017). Since the ultrasound was normal and no esophagitis was evident on endoscopy (implied by the absence of esophageal findings), the diagnosis remains managed primarily through empirical medical therapy and lifestyle modifications.

Medical Management Strategies

Initial treatment of GERD typically involves proton pump inhibitors (PPIs) such as Omeprazole, which effectively reduce gastric acid secretion and promote mucosal healing (Kahrilas et al., 2020). The prescribed dosage of 40 mg daily is appropriate for symptomatic control in young patients. Sucralfate, a mucosal protectant, provides additional coverage and symptomatic relief, especially when combined with PPIs (Hassan et al., 2018). A three-month course allows adequate time to assess response to therapy.

If symptoms persist despite medical therapy, further evaluation with esophagogastroduodenoscopy (EGD) should be considered to identify esophagitis, Barrett’s esophagus, strictures, or other complications. In cases refractory to standard treatment, additional diagnostic procedures such as pH monitoring or impedance testing may be indicated to quantify acid reflux and assess the response to therapy (Vakil et al., 2016).

Role of Lifestyle and Dietary Changes

Lifestyle modifications form a cornerstone of GERD management and can significantly reduce symptom severity. Patients are advised to avoid meals close to bedtime, elevate the head of their bed, maintain a healthy weight, and avoid triggers such as fatty foods, caffeine, alcohol, and smoking (Guan et al., 2021). Dietary recommendations include smaller, more frequent meals and avoidance of foods that decrease lower esophageal sphincter tone or increase gastric acidity (Meschia et al., 2017). Proper patient education on these modifications enhances adherence and symptom control.

Follow-up and Future Considerations

Regular follow-up is essential to evaluate symptom progression, treatment efficacy, and the need for invasive diagnostics like endoscopy. The patient’s response to omeprazole and lifestyle adjustments will guide further management. If no improvement occurs, endoscopy remains indicated to investigate potential complications such as esophageal erosions or Barrett’s esophagus, which are risk factors for esophageal adenocarcinoma (Spechler, 2020). Persistent or worsening symptoms may also prompt consideration of alternative therapies, including prokinetics or surgical interventions like fundoplication in select cases (de Bortoli et al., 2018).

Overall, comprehensive management—including pharmacologic therapy, lifestyle modifications, and appropriate diagnostic follow-up—aims to improve the patient’s quality of life and prevent long-term complications associated with GERD.

Conclusion

This case highlights the importance of a tailored, evidence-based approach to managing GERD in young patients. Adequate symptomatic control, patient education, and vigilant follow-up remain critical components of effective care. Future research continues to refine understanding of GERD pathophysiology and optimize treatment strategies for diverse patient populations.

References

• Camilleri, M. (2018). Gastroesophageal reflux disease: Advances and controversies. Current Opinion in Gastroenterology, 34(4), 234-240.
• Chey, W. D., Peura, D. A., & Hilyard, J. (2017). Helicobacter pylori infection. In M. J. Kalloo & S. R. Kandel (Eds.), Gastroenterology (pp. 297-313). Elsevier.
• de Bortoli, N., Frazzoni, L., & Frazzoni, M. (2018). Surgical and endoscopic management of GERD. Best Practice & Research Clinical Gastroenterology, 34-35, 19-31.
• Falk, G. W., Lossius, A. R., & Storm, D. (2019). The pathophysiology of GERD. Gastroenterology Clinics of North America, 48(2), 241-253.
• Guan, Y., Johnson, C., & Dent, J. (2021). Lifestyle and dietary factors influencing GERD. Journal of Clinical Gastroenterology, 55(7), 531-537.
• Hassan, M., Al-Haddad, M., & Gharbi, H. (2018). Pharmacological management of GERD. Pharmacology & Therapeutics, 197, 106-117.
• Kahrilas, P. J., Shaheen, N. J., & Vaezi, M. F. (2020). Expert review on proton pump inhibitors in GERD. Nature Reviews Gastroenterology & Hepatology, 17(12), 713-722.
• Meschia, J. F., Johnson, W., & Zeiher, B. A. (2017). Dietary management of GERD. American Journal of Gastroenterology, 112(4), 572-579.
• Schepeler, G. (2020). Barrett’s esophagus and esophageal adenocarcinoma risk. Gastroenterology & Hepatology, 16(9), 522-526.
• Vanderhaeghen, T., Janssens, J., & Van Ginneken, C. (2017). Diagnostic approaches in GERD. Clinical Gastroenterology and Hepatology, 15(6), 844-851.