Rationale:
Gastroesophageal reflux disease is esophagitis caused by the reflux of acidic substances and pepsin or bile salts from the stomach to the esophagus, and it can due to decreased resting tone of the lower esophageal sphincter. The decreasing tone can be caused by caffeine drink or alcohol. The rationale of this patient for possibly having a Gastroesophageal reflux disease is due to the symptoms she has, e.g. upper abdominal pain after eating, drinking alcohol and coffee and abnormal weight loss. Chronic chough may be one of the symptoms of GERD; however, the relation is weaker because the patient has COPD, which appears to have a stronger relationship with chronic coughing. The manifestations of GERD include heartburn, chronic cough, asthma attacks, laryngitis, sinusitis, and upper abdominal pain within 1 hour of eating. Additionally, these symptoms will become even more intense as patients lie down or do activities that can increase intraabdominal pressure, e.g. being pregnant, obese, coughing or doing Valsalva maneuver. She also has lost an unexpected amount of weight in a short period, which can be caused by GERD because patients with GERD will have decreased esophageal motility resulting in dysphagia with weight loss. As for the possibly related causes for GERD, the fact that she smokes and takes aspirin can both contribute to the occurrence of GERD. Drinking alcoholic beverages and coffee, on the other hand, can further cause discomfort during swallowing.
Although the patient has several possible reasons which can lead to the diagnosis of GERD, the below are the rationales describing why she may not have a GERD.
- The patient has a bloody stool. Patients with GERD normally won’t have GI-bleeding.
- Obese patients are more likely to develop GERD; however, the patient is in normal weight.
- It has not been said that the use of NSAIDs, the history of H. pylori infection, heart attack, osteoarthritis, acute pancreatitis, diabetes mellitus, hypertension can lead to GERD.
- Genetic factors may play a role in GERD (Argyrou et al., 2018); however, there’s no GERD patient in her family.
- Stress (as she raises two children by herself) may worsen the discomfort; however, the contribution of stress to GERD is still controversial.
To rule out GERD, the diagnosis can be based on history and clinical manifestations. The clinician can complete the Esophageal endoscopy, tissue biopsy, and Impedance/pH monitoring. If the patients have GERD, we can observe hyperemia, edema, erosion, and strictures of the structure through Esophageal endoscopy (Fig. 1, the black arrow), and we can also see epithelium hyperplasia under the microscope (Fig. 2, tissue biopsy). People with Chronic GERD may have Barrett esophagus (Fig. 3, the dark pink area, dysplastic changes), which is the replacement of squamous epithelium with columnar in the lower esophagus caused by gastroesophageal reflux (metaplasia). If the refluxed chyme remains in the esophagus for a longer period, the mucosal injury and inflammation can ultimately lead to ulcerations and precancerous lesions (dysplasia) which can then transform into adenocarcinoma.
Figure 1. Diffuse esophageal erosions and ulcerations (MSD manual professional version, 2019)
Figure 2. Epithelial changes in GERD (A) Normal, nonreactive esophageal mucosa (B) Mild reactive changes (C) Severe reactive changes (Modern Surgical Pathology, 2009)
Figure 3. Barrett’s Esophagus (American Society for Gastrointestinal Endoscopy, 2010)