[51M] Experiencing severe heartburn with stomach pain and morning blood in mouth

Patient Description

A 51-year-old male has been experiencing severe heartburn for over a year, which is persistent throughout the day and night, and sometimes prevents sleep. The patient reports that the heartburn is accompanied by upper stomach pain, described as an upset stomach needing a restroom, with a severity of 7 out of 10. Additionally, for a couple of months, there has been the presence of dark red blood in the mouth upon waking up, originating from the back of the throat, but not occurring every day. The patient also experiences a burning sensation in the esophagus, which started a few months ago. No specific foods have been identified as triggers, and the patient has been taking medicine to alleviate heartburn. Bowel movements are reported as normal, and there are no symptoms of fever or chills.

Arora's Assessment

What might be happening

Based on the symptoms you've described, here are a few possible conditions:

Gastroesophageal Reflux Disease (GERD): This condition occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus, causing heartburn and stomach pain. Over time, chronic inflammation in your esophagus can lead to complications, including bleeding.
- Treatment typically involves lifestyle changes and over-the-counter medications. If these don't help, your doctor might recommend prescription medications or surgery.
Gastric Ulcer: This is a sore that develops on the lining of the esophagus, stomach, or small intestine. Ulcers form when stomach acid damages the lining of the digestive tract. Common causes include the bacteria H. Pylori and anti-inflammatory pain relievers. This could explain your stomach pain and the blood you've noticed in your mouth.
- Treatment usually involves medications to decrease stomach acid. If an H. Pylori infection is present, antibiotics are necessary.
Gastritis: This is an inflammation, irritation, or erosion of the lining of the stomach. It can occur suddenly (acute) or gradually (chronic). Gastritis can be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or the use of certain medications such as aspirin or other anti-inflammatory drugs.
- Treatment involves taking antacids and other drugs to decrease stomach acid, which can help speed the healing of the stomach lining.

Please remember that these are only possibilities and not a definitive diagnosis. You should consult with a healthcare professional for an accurate diagnosis.

What you can do

Here are some general suggestions that might help alleviate your symptoms:

Avoid foods and drinks that trigger heartburn. Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
Eat smaller meals. Avoid overeating by eating smaller meals.
Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.
Elevate the head of your bed. If you regularly experience heartburn while trying to sleep, put gravity to work for you. Place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches.

What you should look out for

You should seek immediate medical attention if you:

Vomit large amounts of blood
Have bloody stools or stools that are black and tarry
Have difficulty swallowing
Experience persistent, unexplained weight loss
Have severe, persistent abdominal pain
Notice a decrease in appetite

Please remember that while I strive to provide accurate and helpful health information, I am not a doctor. Always consult with a healthcare professional for a formal diagnosis and treatment.

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1 yr ago

Top picked over-the-counter products for Acid Reflux (GERD): American College of Gastroenterology Guidelines