Dr. Anshul Varshney
Internal Medicine
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I am 54 years with a weight of 136lbs and a height of five feet. I have these symptoms for the past five months. I have anorexia with loss of appetite. I have dyspepsia with difficulty in swallowing food and water. I have an acidic burn with an outcome of mucin. I have GERD. I have sleep disturbance within an interval of two to three hours of sleep. I have weight loss from 158 to 136 lbs within three months. I have a positive result for helicobacter pylori infection. My upper GI endoscopy showed pan gastritis. I have a past history of piles, feeling of a lump in the throat after taking food. I suffered from a head injury in the last month. I have weakness and dizziness now. Currently, I am taking Aristozyme for 60 days three times a day with Wel liv syrup for 30 days two times a day. I am taking all these tablets for 15 days. Again, I was advised to take Vegazold for 60 days once daily, and Happi for 60 days once daily. I am taking it for 30 days.
Hi,
Welcome to icliniq.com.
I have gone through the attached report (attachment removed to protect patient identity). The important things are pangastritis, solitary rectal ulcer, and anemia. As you have persistent problems related to GERD and gastritis, then this can be resolved by taking drugs. I suggest you take a combination of Domperidone and Pantoprazole. This helps for GERD. At this age, you seem to have significant weight loss and it cannot be neglected. I want to know whether you have anorexia or fear of eating due to gastritis. You have not mentioned your condition regarding blood pressure, ECG (electrocardiogram), and chest X-ray. I am concerned about your weight loss. At this age, it can be due to malignancy. Please mention in detail about your menstrual history. I advise you do a breast examination by yourself or by consulting a surgeon to see for any lump. I also advise you to discuss with your doctor to add a drug called Escitalopram (SSRI). Please review with the above. Thanks.
Patient's Query
Thank you, doctor,
I took a combination of anti-gastric (Omido) and antiemetic drugs for a month but no significant relief was observed. I have 130/83 mmHg of blood pressure and a pulse rate of 74 beats per minute. I have anorexia without any fear of eating. I have not done ECG. I have attached my chest X-ray. I do not have any breast lumps. Kindly advise necessary tests to be done for weight loss. I have attached my biopsy report. My menopause was started ten years back. Please tell me the necessity to take SSRI. I have mucin coming out from my nose especially while taking food. My eruption is getting increased day by day after taking food and it comes at any time. Sometimes, I have mucin coming out through my mouth. After taking medication, it decreases and GERD also gets decreased. I have continuous sleep disturbance. Kindly suggests another requisite department for a consult if required.
Hi,
Welcome back to icliniq.com.
Everything seems to remain related to the acid peptic disease. The solitary rectal ulcer has to be kept into consideration at present. Your report does not suggest any sign of a malignant ulcer. But we should mark it and have a follow-up after six months. I do not find any reason to do more investigations and to consult another specialist for this problem as you were already been evaluated by many specialists. You should know that sleep disturbances and stress increase acid peptic disease and GERD (gastroesophageal reflux disease). So I want to make you sleep peacefully. I do not mind adding a drug to your sleep problems. If you have a good sleep, you will notice a lot of improvement in the symptoms. SSRI (selective serotonin reuptake inhibitors) is used to treat depression and they have other roles to play in other diseases also. Taking Amitriptyline is effective against acid peptic disease. Some people get good sleep by taking SSRI. If it does not help, you can take Etizolam. I hope I am able to solve your query. If you have any other queries, please ask me. Wish you a healthy life.
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Internal Medicine
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