Case Study: Acute Gastroesophageal Reflux Disease (GERD)
Patient Information:
• Name: Laura Martinez
• Age: 35 years
• Gender: Female
• Occupation: Teacher
• Medical History: Laura has a history of occasional heartburn and GERD symptoms,
managed with antacids as needed. She has no known allergies.
Presenting Complaint: Laura presents to the clinic with complaints of severe chest pain and
burning sensation behind the sternum for the past two days. She describes the pain as a sharp,
burning sensation that worsens after meals and when lying down. She reports regurgitation of
sour-tasting fluid into her mouth and occasional difficulty swallowing. She denies any associated
symptoms such as fever, cough, or abdominal pain.
Physical Examination:
• Vital Signs: BP 120/80 mmHg, HR 70 bpm, RR 16/min, Temp 98.4°F (36.9°C)
• Chest Examination: No abnormal findings on auscultation, no signs of respiratory
distress
• Abdominal Examination: Soft and non-tender, no organomegaly
• Other Findings: No signs of anemia or jaundice
Investigations:
1. Upper Endoscopy: Shows evidence of esophageal mucosal injury (erosive esophagitis)
with mucosal breaks and inflammation, indicative of GERD.
2. Esophageal pH Monitoring: Confirms increased acid exposure in the distal esophagus,
consistent with GERD.
Diagnosis: Acute Gastroesophageal Reflux Disease (GERD) with erosive esophagitis
Management: Laura is advised on lifestyle modifications, including avoiding trigger foods (e.g.,
spicy, fatty foods), eating smaller meals, and avoiding lying down after meals. She is prescribed a
proton pump inhibitor (PPI) for 4-8 weeks to suppress gastric acid secretion and promote
healing of esophageal mucosa. Antacids are provided for immediate relief of symptoms as
needed.
Questions for Medical Students:
1. What are the typical symptoms of GERD and how is it differentiated from other causes of chest pain?
2. Describe the endoscopic findings seen in erosive esophagitis.
3. Discuss the pathophysiology of GERD and factors contributing to its development.
4. Outline the pharmacological and non-pharmacological management strategies for GERD,
including the role of PPIs, antacids, and lifestyle modifications.
