Symptoms of Reflux Esophagitis in a 40-Year-Old Male

A 40-year-old male presented with symptoms including chest pain, acid regurgitation, heartburn, and belching, which tended to worsen at night. These are common clinical manifestations of reflux esophagitis, often caused by weakened anti-reflux mechanisms or reduced esophageal clearance. Underlying conditions such as scleroderma or diabetes may also contribute to the development of this condition. After timely medical intervention and appropriate medication, the patient experienced significant improvement.

Basic Information: Male, 40 years old
Diagnosis: Reflux Esophagitis
Hospital: Zhongnan Hospital of Wuhan University
Date of Visit: February 2020
Treatment Plan: Medication therapy including omeprazole enteric-coated capsules, domperidone tablets, sucralfate suspension gel, and compound amino acid capsules
Treatment Duration: One week
Outcome: Noticeable relief of reflux symptoms after treatment

Initial Consultation
The patient was a middle-aged man who walked slowly and supported his abdomen during the visit. He complained of upper abdominal pain, chest discomfort, acid reflux, nausea, and vomiting, which interfered with normal eating and were more pronounced at night. A previous endoscopy had confirmed reflux esophagitis, but prior treatment with acid-suppressive medications and mucosal protectants had not significantly improved his condition. Upon re-evaluation, he was diagnosed again with reflux esophagitis and admitted for further investigation and comprehensive treatment.

Diagnostic and Treatment Process
Following admission, the patient underwent gastroscopy and abdominal X-ray. Endoscopic findings revealed short linear erythematous erosions in the lower esophagus without fusion, along with gastric mucosal congestion. The abdominal imaging showed no signs of organic disease. Based on these results, the diagnosis was reflux esophagitis accompanied by non-atrophic gastritis. The treatment plan included proton pump inhibitors (e.g., omeprazole), mucosal protective agents (e.g., sucralfate suspension gel), and prokinetic drugs (e.g., domperidone) to manage symptoms effectively.

Therapeutic Outcome
After three days of medication, the patient's digestive symptoms such as nausea and vomiting began to subside. By the end of one week, symptoms like upper abdominal pain, chest discomfort, and acid reflux had significantly improved. His mental state also showed positive changes, allowing for discharge. However, long-term maintenance therapy was recommended to prevent recurrence.

Lifestyle Adjustments and Post-Discharge Care
It is essential for patients to avoid strenuous physical activity that might exacerbate symptoms. Light exercises such as walking or tai chi are encouraged to promote overall well-being. Dietary recommendations include consuming bland and easily digestible foods like porridge and noodles, while avoiding spicy or fatty meals that can increase gastric pressure. Elevating the head of the bed during sleep is also advised to reduce nighttime reflux episodes. Moreover, adherence to prescribed medication is crucial to prevent relapse due to premature discontinuation or dosage alteration.

Clinical Insights
Reflux esophagitis is a common and often recurring gastrointestinal condition. While it can be concerning, especially when chronic, early diagnosis and consistent treatment typically lead to favorable outcomes. This case highlights the importance of systematic management, even for patients with long-standing symptoms. With proper care, symptom relief and effective disease control are highly achievable.