Question:
Case Study:
Terry is a 47 year old male financial analyst who presents in clinic with persistent heartburn. It adversely affects his sleep, and causes constant discomfort which is contributing to some degree of anxiety.
Primary Complaint
Terry’s heartburn began approximately 7 years ago, but was only very occasional at the time, and quite mild. Over the next 5-6 years the severity and frequency of discomfort increased, and now he experiences heartburn every day of the week, and for most of the day.
The pain is worse in the evenings after laying down in bed, and he has been advised by his doctor to use a wedge cushion to elevate his upper torso when laying down, however he has not yet done this. The pain is also worse after drinking alcohol, so he very rarely consumes alcohol now (a glass of wine once every 3-4 weeks at social events).
The pain is better for eating small meals frequently during the day, rather than larger meals less frequently.The continuity of the pain is starting to wear on Terry’s mood, and he is concerned about whether he will ever get rid of this problem. When the pain is more severe, he also describes a sense of anxiety and mild nausea, which in turn seems to worsen the severity of his heartburn.
Resting and slow, deep, controlled breathing helps alleviate this anxiety and reduce the severity of the heartburn when it is this acute, however he can’t always do that. In addition, with the pain being worse when in bed, he finds getting to sleep to be more difficult, and that his sleep does not appear to be as restful as it was in the past.
This is contributing to mild fatigue which is worst first thing after waking and late in the afternoon. Terry first sought treatment for the heartburn from his doctor about 3 years ago, after a year of regular use of over-the-counter antacids which temporarily relieved the pain but did not result in long term benefit. He was referred for endoscopy which showed oesophagitis and mild chronic erosive gastritis.
Breath testing and biopsy via endoscopy demonstrated that Terry was negative for Helicobacter pylori infection. At this point Pariet (rabeprazole sodium) was prescribed which after 3 weeks of use provided significant relief of the heartburn, however it caused serious lower abdominal bloating and diarrhoea after 6 weeks of use, so he discontinued the medicine. His GP recommended Rennie chewable tablets as needed, and he usually consumes around 6-10 of these per day.
Past Medical History
Terry’s past medical history is largely unremarkable. Four years ago he had a skiing accident which resulted in a severe right tibia fracture, which was successfully surgically repaired, and there have been no lasting complications.
Dietary & Lifestyle Analysis
- Coffee: Single shot espresso with no sugar, twice daily
- Alcohol: Wine 1 glass every 3-4 weeks
- Vegetables: 4 serves per day (usually 1-2 serves raw salad vegetables, 2-3 serves steamed vegetables)
- Fruit: Large handful of blueberries most nights for dessert, with a tablespoon of unsweetened yoghurt. Heartburn is worse for citrus fruits, bananas and tomatoes, so largely avoids these.
- Red meat or pork: 2 serves per week
- Chicken: 2 serves per week
- Fish: 1 serve every 2 weeks
- Smoked meats: 1 serve every 3 weeks (but mostly avoids now as finds smoked meats also worsen heartburn)
- Water: 600-800mL/day
- Grains: Wholemeal bread averaging 5 slices per day. Brown rice 1 serving every 2 days.
- Dairy: Cheese once every couple of days, occasional milk on a breakfast cereal, unsweetened natural yoghurt most days.
- Sugar: average of one sweet biscuit or 2 squares of milk chocolate per day.
- Non-smoker
- Exercise: Walks approximately 50 minutes total per day on weekdays (around 8000-9000 steps) and most weekends tries to go out either kayaking if the weather is permitting. Prior to the last year, Terry’s diet was significantly different, with large serves of red meat or chicken every day, smoked meats most days, an average of 3 glasses of wine per day (or equivalent alcohol level in the form of spirits), far less vegetable intake, and more refined grains and sugar. The improvement in his diet has somewhat attenuated the heartburn pain long term, however it has not made as much difference as he hoped.
Other Issues
Terry’s work is busy and fast paced, but enjoyable. Whilst he feels the pressure of work, he does not describe it as being adverse, and it does not cause excessive tension or anxiety.
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