Patient is a 63-year-old female. Her problem is the gas problem with abdomen and chest pain. She had constipation before, and now her bowel movement is better.
She regularly takes Atorvastatin 20 mg, Riva retinol 50 mg, Sandoz Perindopril + Indapamide 4 -1.25 mg, Calcite D 500 mg, Zantac (as needed), Dexilant for a week and Domperidone 10 mg for one month, and Nexium 40 mg for the last four weeks.
Two weeks ago, she did an abdominal ultrasound, and the result shows normal. One year ago, she did a colonoscopy and gastroscopy, and polyps were removed. Since the radiology test results are in French, I am not attaching them. The blood test report IgG, IgA, IgM are normal.
Even after all the above tests and medication, her gas and pain problem in the abdomen and chest remains the same. She experiences uncomfortable feeling, especially when she is sitting in a position or bend in forward to take a deep heavy breath.
Is there any other test (e.g., stool) she needs to do? Any medication advice that she should continue? As she has high blood pressure Nexidum and Domperidone, which is more effective and good for her? Are they safe for long term use? Can such gas and gas pain increase blood pressure? Any other suggestion, including eating habits or life style change?
Welcome to icliniq.com.
Well, I would need to know about her weight at movement. Since abdominal fat can simply cause the feeling of gas and bloating. Secondly, I also want to know if she had her complete blood count, thyroid profile, and liver function tests and diabetic status checked?
The answer to your first concern is yes. She needs some more testing as I write below. Plus stool test to rule out H.pylori infection.
For now give her tablet Itopride OD 150 mg once daily half hour before breakfast. She can continue with Domperidone which is rather safe and effective particulaly in her gas problem. Nexium is an acid suppressant medication, she has gaseous symptoms predominantly and not acidic symptoms. So she can avoid taking Nexium. However, at times if acidity or acid reflux she can take it on need basis. They are safe for long term use.
Based on her current weight I may advise her to reduce weight. Reduce corbohydtates intake. Particularly for her gas problem she should avoid high FODMAPS diets. She should always take low FODMAPS diet. And she should try diaphragmmatic breathing also called as belly breathing. Just search this term on youtube and you will find how it is performed. She should do on empty stomach every 4 to 6 hourly while lying flat over bed or mattress.
I would appreciate if you could share me the above information about her diet and weight and also alcohol habits and routine exercises, I would be able to give her advise on those as well.
Get the following tests if not done already. If done kindly upload the reports.
2, TSH, FT4.
4. Fasting lipid profile.
5. Stool for H.pylori antigen.
6. Serum amylase.
Thank you doctor,
Her height 5 feet 2 inches, current weight is 70 kg. She is not much active for the last six months since the COVID-19 lockdown started.
In the morning, she takes milk, banana, cereals or bread, egg or bread and butter, and tea.
She takes rice, fish, chicken, vegetables or spinach, and a Multivitamin tablet for lunch.
At 4.30 PM, fruit or dry snacks, or prune juice.
For dinner, bread + vegetables or fish or chicken.
Before sleep, she takes lactose-free milk.
She is non-alcoholic. Is it acceptable to take a probiotic drink or tablet every day? How many times a day should she take Domperidone and the dosage? For how long should she take tablet Itopride OD 150 mg?
I have attached the blood test report. If you think more tests need to be done other than those already listed, please let me know.
Welcome back to icliniq.com.
Thanks for providing me further important information about your health. Well, the diet is completely fine, except that she should avoid prune juice. The prunes contain a high level of fructose and other fermentable carbohydrates. If she wishes to take prunes, then give her as whole fruit, rather than juice. This rule applies to all fruits as well. Take whole fruit instead of juices. The meat products like the ones you mentioned are alright. Fish, chicken, and pork are fine. But avoid red meat, lamb, and avoid sausage of all types.
I suggest that she should use a small course of antibiotics for three weeks. Take tablet Rifaxamin 200 mg thrice daily for 21 days. This is a safe antibiotic that works only in the gut. Almost 99% of the drug remains in the gut. This will correct dysbiosis (abnormally high levels of large bowel type bacteria in the small bowel) so once bacteria in the large bowel migrate to infiltrate small bowel, and start producing gases when coming in contact with meal contents, commonly carbohydrates. I recommend that she should use it for three weeks. After that, I would consider her giving twice a day probiotic medicines. The commercially available tablet is Ecotec twice daily after meals. But this would be started once she finishes the above antibiotic course.
Domperidone 10 mg thrice daily half an hour before meals can be taken for four weeks until a definite improvement is seen. Tablet Itopride 150 mg once daily, half an hour before breakfast daily, again for four weeks.
I want you to monitor her sugars twice daily for a week. One before breakfast in the morning, and other in day time two hours after taking lunch (post prandial sugar). Make a chart of it for at least one week. Show it to me the next time you follow up with me. I see her HbA1c is just borderline (0.59%). That is why I am asking for sugar monitoring.
Lastly, I want you to read the FOMAPs Charts. This would be helpful in guiding which foods to be avoided and which foods to be allowed.
I have reviewed her previous history and diagnosis (attachment removed to protect patient identity). I agree with the rest of the medicines you described previously, plus once a day Multivitamin and calcium supplements.
Small intestinal bacterial overgrowth /intestinal dysbiosis. Idiopathic gastroparesis. Functional gas and bloating.Investigations to be done:
Sugar monitoring for a week.Probable diagnosis:
Small intestinal bacterial overgrowth /intestinal dysbiosis. Gastroparesis. Functional gas and bloating.Treatment plan:
Tablet Rifaximin 200 mg thrice daily for 21 days after meals. Domperidone and Itopride both for four weeks and Nexium as required. Continue with rest of medicines.Regarding follow up:
Follow up in one week with sugar chart. Or earlier if any concerns.
Thank you doctor,
The patient is 60 years old. She regularly takes some medication, which I mentioned above. She is suffering from gas, abdominal pain, and acid reflux almost for the last four months. Although it is now under control.
Please find the attached new blood test reports, including lipase showing 66 U/L, which is slightly above normal, which is 6 – 60 U/L. She will do a urea breath test within two weeks. She started taking Domperidone 10 mg three times a day. Since she started taking this medication, her uncomfortable feeling for gas is much less or almost gone, with no acid reflux nor abdominal pain. Before taking Domperidone, she took Esomeprazole, and it did not help her stomach gas and pain.
In the previous week, her blood pressure reading shows 141/80, 138/80, 140/79, 150/83, 154/89, 145/89, 149/86, and 150/90. Her previous readings one or two months before were much less than this.
The doctor prescribed for ECG, 24-hour BP monitor, and urea breath test. Can Domperidone or Esomeprazole increase blood pressure? If it does, can she continue with one 10 mg Domperidone tablet a day rather than three tablets? Will this be good for both her high blood pressure and gas? If yes, should she start taking one 10 mg Domperdon immediately? When is the right time (morning/afternoon/evening)? Or should she stop taking it? Or one 10 mg Domperidone only when needed? Is Dexilant 30 mg once a day will be a better alternative to Domperidone for her now? If yes, for how long with her present situation? The blood test was done seven weeks ago for lipase showing 66 U/L, which is slightly above normal, 6 – 60 U/L. Does this have any link with her abdominal pain and gas? Is she currently on the right medication or treatment for this higher lipase with Domperidone? What might be the cause of this?
When the lipase test was done at the hospital, the doctor informed me that when the patient did a colonoscopy test one year ago, the injury caused a higher value of lipase. Should she need to do a new lipase test? Is 24-hour ambulatory blood pressure monitoring (ABPM) the same as the Holter monitor test? If not, does the Holter monitor test provide 24-hour BP readings? I am attaching her previous two ECG reports for your suggestions. As some words are in French, I am translating them as below.
Sinus bradycardia T ion abnormality, possible previous ischemia abnormal ECG. Sinus bradycardia nonspecific ST segment and T wave abnormality. ECG abnormal. No previous ECG was available.
Welcome back to icliniq.com.
I am glad you have some relief in your gas and bloating symptoms with medicines. I want to know first, have you completed the antibiotic course of Rifaximine which I have suggested?
Yes, Domperidone and Esomperozole both cause slight elevation of the blood pressure. Well, given her predominant gaseous symptoms, I suggest continuing with Domperidone. I can stop Esomeprazole for now and take on a need basis whenever I have pain, acidity, or acid reflux symptoms burning in the chest throat. You can decrease the dose of Domperidone 10 mg twice daily instead of thrice daily. One before breakfast and another before dinner. I think with this, her blood pressure will normalize in another few days, and her gaseous problem will remain in remission.
Dexilant is the same as Esomeprazole. It is for acid-related symptoms, not gas-related symptoms. So since I have asked to stop Esomeprazole and take only when need arise. Dexilant is an alternative to Esomprazole not Domperidone.
The lipase levels are normal. It is completely ignorable. And it does not cause a gas problem if elevated. A value of more than 100 is always a concern. But here, the value is slightly elevated. I would say it is not abnormal. A year back, colonoscopy with complications has nothing to do with current lipase levels. Since it is not elevated, so no point in discussing what it is implied to.
However, repeating lipase is a good idea otherwise, although you do not have symptoms suggesting pancreatitis (inflammation of the pancreas-a common cause of elevation of the lipase). ABPM monitor BP in 24 hours, and Holter monitor ECG changes in 24 hours. Both are different. At times both studies performed at one time. I have seen the ECG as well, which you uploaded.
Yes, ECG shows a little lower heart rate, but no significant ischemia changes. I also agree with going for a Holter monitoring if required. I am not an expert in cardiology, so I cannot say how to follow ECG changes. Your cardiologist is the best person to give a suggestion on this.
Thank you doctor,
Antibiotic course of Rifaximin was not prescribed by the doctor here yet. Not sure whether or not they will do it after the urea breath test in two weeks. Do you have any suggestions that I can discuss with the doctors here?
Barium swallow test barty throat and double contrast esophagogram - Normal examination. There was no Zenker's diverticulum or sign of achalasia in the upper esophageal sphincter. No gastroesophageal reflux. Swallowing occurs normally. There is a good tilt of the epiglottis. There is no stasis in the vallecules or the pirform sinuses. There is good relaxation of the cricopharygia.The esophageal transit is carried out normally. There is no hiatus hernia. No sign of peptic involvement.
Cecum polyps - Hyperplastic polyp fragments (4).
Ascending colon polyp - Trublous adenoma.
Duodenum biopsy - Peptic duodenitis. Absence of pathogen. Absence of dysplasia and malignant neoplasia
Stomach biopsy - fragments of the fundal-type gastric cloud without significant histological lesion. Absence of intestinal metaplasia. Absense of Helicobacter pylori (special coloring in agreement).
Her latest Lab test report for glucose shows normal and I did her glucose test for the last seven days using home use kit that also shows normal or medium between 4.8 to 5.6.
Her cultural food involves spice. But she tries to limit spicy food as much as possible. She claims to have the gas problem for a long time and take Rantac for this for 2 weeks. No abdominal pain, no feeling of food stuck in throat, no heart burn, etc. Even two weeks ago she used to say when she is in a sitting position she feels uncomfortable heaviness in the chest or upper abdominal area need to take a deep breath or stand up, now this is much less or almost gone since last eight days, and her bowel movement good.
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I do not think that she has gastroesophageal reflux disease (GERD). She seems to have predominantly gas symptoms. However, please note that it is not uncommon to have some acid related symtoms like stomach pain accompanying with gas. Acid reflux or GERD means that there is evidence of reflux of acid in to esophagus. The main symptoms a GERD patient show are chest burning, acidic taste in the mouth or throat, constant regurgitation of the acid or water brash in the mouth. You see neither her symptoms, nor her barium esophagogram which you shared me now, is consistent with GERD.
It is simply gaseous symptoms and the possible causes which I mentioned are small intestinal bacterial overgrowth SIBO, functional bloating and gas, functional dyspepsia or gastroparesis (both have slowing of stomach a primary underlying problem).
Please remember that the one diagnosis may accompany others. We gastroenterologist often do not check each and every individuals. Instead I consider giving emperical therapy at first and establish the diagnosis retrospectively. This I feel a cost effective option as well as optimal way of providing relief to patient. Considering the above possibilities I suggest to start Rifaximin 200 mg thrice daily. Do diaphragmmatic breathing (belly breathing). Avoid HIgh FODMPAs diet and take Domperidone 10 mg twice daily with Esomprazole 40 mg whenever I feel pain or acidity.
Urea breath is important to establish whether she has H.pylori infection. But ideally the acid suppressants medications like Esomprazole has to be stopped at least a week before going for the test.
I have read the colonoscopy report (attachment removed to protect patient identity). This is low risk colonoscopy meaning there is no need to repeat it sooner but just according to surveillance schedule in your country. I would do a colon at 10 years after this index colonoscooy.
Her symptoms improvement seems to be in response of the medications which I have suggested, plus due to home remedies which you started taking.
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