A 24-year-old female student presents with thoracic pain, but this is only one of her complaints.
Background: A 24-year-old female patient presented to her primary care physician with intermittent thoracic pain. This was a female student in her final year of study who had already sought medical attention in recent months for migraines, dizzy spells, and abdominal bloating, as well as with stool irregularities. However, physical examination and laboratory values, as well as an abdominal ultrasound, showed no abnormalities. The patient was then treated with proton pump inhibitor therapy (2×20 mg/d Pantoprazole®). The symptoms improved insignificantly as a result, and the medication was discontinued within a few days due to diarrhea-like side effects.
History and diagnosis: The patient was referred to a gastroenterologist for further evaluation. Gastroscopy revealed no evidence of reflux esophagitis, hiatal hernia, or gastritis. Due to the patient’s high level of distress, a physiological examination was also performed. High-resolution manometry revealed a hypertensive motility disorder in the form of a nutcracker esophagus. Although esophageal acid exposure was within the normal range, 24-h impedance pH-metry detected a significant association between the reflux event and patient symptoms. This constellation is diagnostic for reflux hypersensitivity (Rome IV and Lyon criteria).
Therapy: The patient was treated with an alternative proton pump inhibitor for two weeks (2×20 mg/d Nexium®). Since the patient did not tolerate the drug, an alginate preparation (Gaviscon® 5 ml) was prescribed instead to be taken as needed. In addition, Metamucil® and Iberogast® drops were recommended to treat the lower abdominal symptoms typical of irritable bowel syndrome. With this combination, thoracic and abdominal symptoms improved. For treatment of therapy-refractory pain, therapy with low-dose antidepressants was discussed. However, after successfully completing final examinations, the patient no longer considered the symptomatology to be so problematic.
Comment by Prof. Mark Fox, MD: Gastroesophageal reflux disease is also a functional gastrointestinal disorder. An important feature in many patients is increased visceral sensitivity. This is often related to physical and psychosomatic stress factors. Patients with reflux hypersensitivity also tend to have an increased prevalence for other functional pain syndromes. The treatment is often complicated by side effects. In such cases, the administration of locally active preparations such as Gaviscon®, which rarely have systemic side effects, can be helpful.
