Continuing our monthly series, Dr Nazeli Manukyan asks readers to suggest what is causing persistent heartburn in this female patient. Put your suggestions in the comments below. Answer to be revealed soon!
Note that details of the case have been altered to protect individuals’ identities
A 39-year-old female initially presented to the GP practice with reported episodes of diarrhoea and persistent heartburn.
Blood tests showed normal FBC, CRP, ESR, negative coeliac screen, negative stool culture and normal faecal calprotectin. The patient failed to respond to different proton pump inhibitors (PPIs) – omeprazole, pantoprazole and esomeprazole at high doses – and to metoclopramide.
The patient was referred to gastroenterology for investigations which revealed normal gastroscopy, negative H.pylori, normal ultrasound and normal 24-hour oesophageal pH studies.
A follow-up gastroscopy was planned by the gastroenterology team. It was at this point, around 18 months after her referral, that I met the patient for the first time. The patient did not report any other symptoms apart from ongoing bothersome heartburn episodes.
What do you think was going on? What other investigations did the patient require?
Put your suggestions in the comments section below. Answer to be revealed soon!
Dr Nazeli Manukyan is a GP based in Surrey
For more diagnostic puzzles, see previous articles in our Case of the month series:
- Case of the month answers: What was causing this patient’s nausea and tingling fingers? – Pulse Today
- Case of the month answers – what was causing this patient’s panic episodes? – Pulse Today
- Case of the month – answers: Did you get the cause of the patient’s sudden memory loss? – Pulse Today
- Case of the month answers: Did you get what caused this man’s pityriasis rosea? – Pulse Today
- Case of the month answers – what was the cause of this young worker’s abdominal pain? – Pulse Today
Have you handled a case which had a slightly surprising outcome? Perhaps an elderly man with non-vertigo dizziness? Or an unexpected cause of bradycardia? Would you like to share your case studies with us to help support and inform GPs? Please get in touch if you would like to contribute! [email protected]
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I’m sorry, but I am not sure why bloods done so soon. I want at least one MSU and a fuller drug and food history and more about the diarrhoea before I go for the bloods and PPIs, please.
These cases have to be “solvable” from the history to be of interest.
This is basically “patient has heartburn which is not better with PPIs and all test are normal, what’s wrong?”
Any correct answer would have to be lucky guess than based on a clue in the presentation.