For months, Michael was having trouble swallowing, and he often felt
as if he had a lump in his throat. His voice sounded hoarse, and he had a
dry cough, which he attributed to smoking. Even more troubling, Michael
was plagued by mild chest pain. He was especially worried because his
dad died of heart disease. Michael managed a retail store, and on the
nights when he worked late, he often ate dinner right before bed. This
led to indigestion and insomnia. Taking antacids usually helped his
stomach and the pyrosis—but not the pain in his chest. One night, the
pain was especially severe; though it eased a short time after it
started, he was still having trouble swallowing. Concerned, Michael went
to see his physician’s assistant the next week. Because of Michael’s
concern about his heart, his PA ordered an electrocardiogram (EKG). When
the results turned out to be normal, Michael wondered if his
symptoms—especially the trouble swallowing—might be due to a
gastrointestinal problem. His PA agreed and gave him a referral to our
In taking Michael’s medical history, I learned that he had an
irregular eating schedule. I asked about his diet, and Michael told me
that he had a passion for chocolate, spicy foods, and coffee. I
performed a physical exam and did not find any abnormalities. Because
Michael reported having trouble swallowing, I wanted to make sure that
there was no serious damage to his esophagus from his digestive
problems. I had him undergo an esophagogastroduodenoscopy, a test that
involves being sedated while an endoscope is inserted into the mouth and
down the stomach. The endoscope allowed me to check for a hiatal
hernia. Hiatal hernias can also cause reflux and pyrosis.
Based on Michael’s description of his symptoms, I suspected that he
had gastroesophageal reflux disease (GERD), which occurs when the lower
esophageal sphincter at the bottom of esophagus relaxes, allowing
stomach acid to leak back into the esophagus. Over time, the stomach
acid can irritate and damage the delicate lining of the esophagus.
Fortunately, he did not have any significant buildup of scar tissue (in
some GERD sufferers, scar tissue builds up in the esophagus, which can
lead to blockages as well as cancer-causing tumors). Michael also did
not have a hiatal hernia. What he had was a classic case of GERD.
Although most people with GERD suffer from frequent pyrosis, some do
not. Some patients have chest pain, a lump in the throat, a cough, or
hoarseness—which is exactly what Michael had described. Most patients
can be diagnosed with GERD based on symptoms alone: iIf they respond to
treatment, then the diagnosis is confirmed.
In order to ease his symptoms and prevent future damage, I prescribed a
proton pump inhibitor (PPI) drug, which reduces the acid that is
secreted in the stomach. I explained to Michael that medication was just
part of the equation: He also had to make lifestyle changes. I urged
Michael to limit his intake of coffee, chocolate, and fried or spicy
foods, all of which can stimulate acid production in the stomach. In
addition, he had to lose weight and stop smoking. GERD occurs when
stomach acid leaks back into the esophagus, and smoking weakens the
sphincter that separates the esophagus from the stomach. Excess weight
puts pressure on the stomach, which may cause acid to back up into the
esophagus. Finally, I advised him to eat smaller meals. Not only would
eating smaller meals help him lose weight, but it would also prevent his
stomach from becoming too full, which puts pressure on the lower
esophageal sphincter and increases the chance that the food will reflux.
Over the next 3 months, Michael lost 8 pounds. He was taking his
medication, and he had cut back his coffee consumption to one cup per
day. Although he could not resist chocolate and Mexican cuisine, Michael
started viewing these foods as occasional treats. He recently started a
smoking cessation program at the local hospital. As a result, his chest
pain had virtually disappeared, and he was no longer having trouble
swallowing. His voice even sounded less hoarse. Now that his symptoms
have eased, I was certain that I had diagnosed him correctly.
1. The esophagus is a muscular tube through which ingested food
passes from the pharynx to the stomach. It is aided in this action by
gravity and peristalsis. What is peristalsis?
2. GERD is an abbreviation for gastroesophageal reflux disease. Define the word parts that make up the word gastroesophageal.
3. The doctor decides that Michael does not have a hiatal hernia. What is this? What are they symptoms of a hiatal hernia?
4. Michael underwent an endoscopy of his esophagus and stomach. Name
two lower gastrointestinal system procedures that involve an endoscope,
and describe why they are done.