Case Study: Ms. Li, 43, Successfully Manages Non-Erosive GERD with Medication and Dietary Adjustments

Overview: Ms. Li, a 43-year-old patient, experienced persistent retrosternal burning, post-meal bloating, and belching for over six months. Initial self-administered acid-suppressing medications showed little effect. Despite a normal endoscopy result, she was diagnosed with non-erosive gastroesophageal reflux disease (GERD). With a combination of targeted medication and lifestyle changes, her symptoms significantly improved within two weeks of outpatient treatment.

Patient Profile:
- Age: 43
- Gender: Female
- Diagnosis: Non-Erosive GERD
- Treatment Location: General Hospital of Tianjin Medical University
- Treatment Period: July 2021
- Treatment Method: Oral medications (Hydrotalcite tablets, Mosapride Citrate tablets) + dietary modifications
- Outcome: Noticeable symptom relief and full recovery

Initial Consultation:
Ms. Li reported experiencing retrosternal burning and discomfort four to five days a week for over six months. These symptoms were often accompanied by bloating and belching after meals. She had tried over-the-counter acid suppressants without success, leading to a decline in appetite and unintentional weight loss. Although she maintained a generally healthy lifestyle—avoiding smoking, alcohol, coffee, and strong tea—a recent endoscopy showed no abnormalities. Her anxiety and depression score was mild at 5, ruling out somatic symptom disorder related to mental health. Based on clinical presentation, non-erosive GERD was suspected, and further diagnostic tests were recommended.

Diagnostic and Treatment Plan:
To better understand the underlying cause of Ms. Li's symptoms, esophageal manometry and 24-hour pH monitoring were performed. The manometry results revealed low lower esophageal sphincter (LES) pressure, reduced relaxation, and impaired esophageal clearance. The pH monitoring showed a DeMeester score of 0.49, below the pathological threshold, indicating no significant acid reflux. However, symptoms were still consistent with reflux, primarily non-acidic in nature, with mixed gas and liquid content.

Based on these findings, lifestyle and dietary modifications were emphasized. Ms. Li was advised to eat smaller, more frequent meals, avoid lying down immediately after eating, and improve eating habits. Additionally, she was prescribed Hydrotalcite to neutralize stomach acid and Mosapride to enhance gastrointestinal motility.

Positive Outcomes:
After two weeks of consistent treatment and lifestyle changes, Ms. Li reported a significant reduction in her burning sensation and post-meal discomfort. Her appetite improved, and she regained energy, which positively impacted her work and daily life. A follow-up phone call two months after discontinuation of medication confirmed that she remained symptom-free and had fully resumed her normal routine.

Key Recommendations for Long-Term GERD Management:
While Ms. Li's recovery was successful, long-term maintenance is crucial. It is highly recommended to continue eating small, frequent meals, avoid overeating, and remain upright after meals. Light walking after eating can aid digestion. It's also important to limit intake of caffeine, alcohol, chocolate, and fatty foods. Regular physical activity and stress management techniques can further reduce the risk of recurrence and support overall digestive health.

Final Thoughts:
Gastroesophageal reflux disease is a global health concern, with increasing prevalence in China. If left untreated, it can lead to complications and significantly affect quality of life. Ms. Li's case highlights the importance of timely medical intervention. Although her symptoms had persisted for six months before seeking care, early diagnosis and a comprehensive treatment plan ultimately led to a positive outcome and full recovery.