Case Study: Indigestion & Acid Reflux

Indigestion & Acid Reflux

SUMMARY

A patient sought treatment for bloating and acid reflux that has been bothering her for over a year. These symptoms were accompanied by pain in her abdomen, as well as a lot of burping. After three treatments, the pain, bloating, and acid reflux were eliminated. After the fifth treatment, the burping was almost completely eliminated to the point that she barely noticed it. The patient was discharged after the sixth treatment.

Patient History

A 27 year old female patient came into the clinic complaining of indigestion and acid reflux that has been plaguing her for 1.5 years. Accompanying symptoms “feeling puffy all over”, distension in right lower quadrant of the abdomen. The issues were constant, triggered by eating or drinking fluids, especially after lunch, and fatigue. The patient also noted that her symptoms were worse when she was travelling. Her symptoms were alleviated by eructation (burping), drinking peppermint or spearmint tea, and activity (moving). Symptoms occur daily, especially in the evenings. The patient is also lactose intolerant. In addition, she also suffers from constipation with hard stools, depression, cold feet, irritability, and tinnitus (ringing in the ears). The patient’s menstrual cycle is also irregular, and she suffers from PMS symptoms of bloating, breast tenderness, and is more emotional and irritable.

Objective Findings

The patient's abdominal pain was worse on pressure, especially in the RLQ.

The patient’s tongue is pale red with toothmarks, a thin and white tongue coating, with normal sublingual veins.. Her pulse is 75 BPM and thin.

Diagnosis

Rebellious Stomach Qi (due to Stomach Qi Stagnation) breeding Heat: Burping, acid reflux

Spleen Qi Deficiency: Lactose intolerance, tooth marked tongue

Liver Qi Stagnation: PMS, Irritability, tinnitus, Cold Feet, constipation

Principle of Treatment

Move Stomach Qi to relieve Stagnation, Soothe Liver, Tonify Spleen

Treatment Plan

Treat once a week for 10 weeks. Modalities: Traditional Chinese Acupuncture.

Results of the first treatment

The patient’s symptoms were relieved for three days after treatment until she ate out and had stomach pain and urgent bowel movements.  Five days after treatment the patient ate a “bad lunch” and suffered from bloating and gas. Patient has started keeping a diet diary. Has noticed that avoiding sugary items helps. There were 7 days between the first and second treatments.

Results from second treatment

The patient has had no symptoms since the second treatment. Patient was travelling between the second and third treatments and did not have any issues. There were 9 days between the second and third treatments.

Results from third treatment

The only symptom that the patient has noticed since the last treatment is burping. The bloating and discomfort has not been apparent. There were two weeks between the third and fourth treatments.

Results from fourth treatment

The patient has noticed a reduction in symptom of burping since the last treatment. No other symptoms have recurred, even with eating out. There were five days between the fourth and fifth treatments.

Results from fifth treatment

The patient’s burping is hardly noticeable since the last treatment, only occurring with oat milk and other milk alternatives. There were 11 days between the 5th treatment and the final 6th treatment. Patient was discharged after the 6th treatment, as her symptoms have been very manageable by continuing to watch her diet.