Gastrointestinal (GI) disorders are the most frequently presented illnesses affecting millions of people of all ages in across both genders. GI symptoms can lead to discomfort that ranges from inconvenience to deep personal anguish. Among these illnesses, gastro-esophageal reflux disease (GERD) is the most common affecting 10-20 percent of people living in the western world (Badillo and Francis, 2014).). GERD is a persistent digestive illness. It happens when stomach acid surges back to the esophagus. This reflux irritates the lining of the esophagus thus leading to GERD.
Gastritis is a potential diagnosis for this case. While this condition can be caused by the bacterium that causes ulcers, it can also be caused by the habitual use of some pain killers or too much consumption of alcohol. Patients often present with epigastric burning, pain (indigestion), or discomfort. The will also complain of nausea, vomiting, flatulence (Zeid and Confer, 2017). Halitosis could also be present. Peptic ulcer disease (PUD) could be another potential diagnosis with patients presenting with mid-epigastric pain that can be relieved with antacids and is also prevalent in smokers and patients with old age (Chung et al., 2015). Besides that, patients will also show signs of anorexia, weight loss that could be accompanied by nausea and vomiting.
According to the patient’s presentation, GERD is the most likely diagnosis for his condition considering the constant heartburn for which he uses antacids for relief. GERD is an illness that can be relieved with antacids. Besides, the patient also has a history of smoking and the use of alcohol which could lead to GERD. The patient also uses NSAIDs which could also result in GERD. To find out more about the condition, it would be necessary to ask the patient when he experiences heartburn the most.
Evaluation through endoscopy would be appropriate considering the patient’s advanced age to eliminate any chances of Barrett’s esophagus. I would recommend proton pump inhibitors (PPIs) or laparoscopic fundoplication which are common treatment options for GERD (Zeid and Confer, 2017). I would also commend that the patient reduces alcohol consumption and smoking (Kubo et al., 2013). He should also reduce his meal portions and avoid lying down for 3-4 hours after having a meal.
- Badillo, R., & Francis, D. (2014). Diagnosis and treatment of gastroesophageal reflux disease. World Journal of Gastrointestinal Pharmacology and Therapeutics, 5(3), 105–112. http://doi.org/10.4292/wjgpt.v5.i3.105
- Chung, C.-S., Chiang, T.-H., & Lee, Y.-C. (2015). A systematic approach for the diagnosis and treatment of idiopathic peptic ulcers. The Korean Journal of Internal Medicine, 30(5), 559–570. http://doi.org/10.3904/kjim.2015.30.5.559
- Kubo, A., Block, G., QuesenberryJr, C.P., Buffler, P., & Corle, D. (2013). Dietary guideline adherence for gastroesophageal reflux disease. BMC Gastroenterology, 14:144. https://doi.org/10.1186/1471-230X-14-144
- Zeid, Y., & Confer, J. (2017). Standards of Care for GERD. US Pharmacist, 41(12):24-29. https://www.uspharmacist.com/article/standards-of-care-for-gerd