So it's a clinic letter for pauline jones alpha277332 82 year old lady gastroenterology clinic that's an ibd clinic actually so investigations list ogd april 2025 small hiatus hernia reflux esophagitis histologically grade hill grade 2 goj lacrity incidental duodenal diverticulum so diagnosis previous colectomy for colitis 02/2004 previous diagnosis of barrett's esophagus but multiple normal upper gi endoscopies other medical problems so actually in the diagnosis it's ulcerative colitis with total with previous total colectomy and ileostomy 2004 other medical problems type 2 diabetes hypothyroidism copd severe aortic stenosis with tavi in april 2023 tia in last april no april 2023 following her last op following well tavi april 2023 awaiting knee replacement previous barrett's esophagus medications list alagliptin 12.5 once per milligrams once per day estriol vaginal cream hydroxazine 25 mg at night gaviscon is required ursodeoxycholic acid 207 hundred and 50 mg at night menthol 1% cream as needed cetirizine 10 to 20 mg twice a day humulin I insulin as required gliclozide 30 mg modified release 60 mg modified release within the morning azelastine 140 microgram per dose nasal spray 1 puff twice per day famotidine 40 mg at night anoro ellipta 55 micrograms / 22 micrograms dry powder inhaler 1 dose per day atorvastatin 80 mg at night levothyroxine 50 micrograms in the morning gtn 400 micrograms as required clopidogrel 75 mg once a day levothyroxine 100 micrograms once in the morning 500 paracetamol 500 milli or 1 g as required up to 4 times a day in the past medical history as well there's multiple lacunar infarcts cataracts bilateral osteoarthritis testing back in the investigation section ct abdomen and pelvis march 2025 for reduced stoma output and abdominal pain long standing parasternal hernia with no evidence of acute bowel obstruction new mural thickening of the rectal stump which may indicate active inflammatory bowel disease clinical correlation advised most recent blood tests april 2025 chronic kidney disease with creatinine 105 alp 173 hemoglobin 105 platelets normal white cells and neutrophils normal and then back in the ogd and the investigations histology lower esophageal biopsies and mid esophageal biopsies mild chronic inflammation consistent with reflux esophagitis hi is that missus pauline jones hi good morning I'm doctor robert miller and I'm 1 of the gastroenterology registrars we met at the time of your recent endoscopy we had the pleasure but I'm calling you today for clinic I hope I've caught you at a reasonable time good I'm glad good I'm glad so I understand you have ulcerative colitis and you had surgical management for that with the complete removal of the: back in 02/2004 and then you recently had a ct scan under the surgical team and there were some concerns that your rectum might be a bit inflamed do you you have any symptoms from your back passage fine that's good nothing comes out excellent good and how's your ileostomy mhmm okay how many times a day will you empty the bag or change the bag mhmm is that what sore the where it touches your skin mhmm that's okay okay fine okay fine twice in the day and once every night fine and do you get muscle cramps or feel particularly thirsty or anything like that yeah that's true mhmm yeah of course yeah fine ew and that's around your when your stone is working or in the in the day that's okay and there was some some I I think you had that you had the upper gi camera test the upper gi endoscopy because of reflux symptoms is that is that what you're talking about yeah your reflux is still bad okay tell me about that mhmm behind your breastbone okay and when do you get tend to get the symptoms fine really okay so and do you sleep flat or slightly propped up or what's your 2 pillows yeah okay april thing but it doesn't tend to help at night I bet mhmm mhmm okay I'm sorry to hear that your your endoscopy showed that you have a hiatus hernia did did I did I explain to you did you have some sedation were you sleepy or did I explain to you what that means at the time of your endoscopy you had a bit of sedation so you may not remember me talking to you after but a bit of the stomach we're designed really we you know in all parts of our in other places where we need 1 1 bit of the body to be separate to another we have a tight ring of muscle like a sphincter say for example around our mouth or around our bum we want things to be able to stay on 1 side and then have control of when when they go to the other side but in the stomach we're we're not like that we've got a single tube of of skin mucosa on the inside and then that is wrapped by a ring of muscle but the muscle isn't in the lining of the oesophagus and stomach it's outside it's very common that for whatever reason whether it's our western diet or stress or whatever it may be we commonly have a looseness or weakness in that muscle which means that a bit of the stomach slips up into the chest and then acid can more easily wash over the lower gullet and it very commonly causes the symptoms you described where you get acid washing up over the lower gullet at nighttime if and that's because you don't have that tight ring of muscle and so acid is more likely to just travel up with gravity the things that can help are decreasing the acid production you're already on famotidine at a good dose you take 2 of them at night fine and so that's as I prescribe I see doctor gallo yeah yes good fine yeah and I can see it's on your repeat prescriptions now so next time you go for a repeat prescription you should be able to get famotidine twice a night which I hope will help to dampen down the acid production but even so production but even so some people can get acid washing up there and do you through the ileostomy or or are you talking about upper gi wind where you have bloating and burping bloating and burping at the same time yeah and and that's that it that is indicative of having nothing to keep things in the right place we all swallow a bit of air but unfortunately if you haven't got a muscle keeping it tight there then the air is more likely to come up you'll burp more instead of have taking that air down through your gut and you'll and you'll have some acid wash up with that burp over your lower gut and that can be very sore if your symptoms are all at night not all at night burpings during the day yeah do you find the gaviscon helps better during the day yeah I know what you mean yeah and because gaviscon forms a a cap like a floating cap over the acid are you using the single action or the double action gaviscon that's okay oh yeah fine so the ordinary gaviscon forms a cap you might do better with the double action gaviscon that stuff kind of coats the lower gullet as well to try and prevent any acid getting through to the sensitive tissue there and then the other thing you could do would be to lift the head of the bed ever so slightly I'm talking about putting a book or a brick under the head posts of the bed just to lift it ever so slightly you won't notice it but it's just enough to keep a bit of acid in the stomach instead of it washing up over the gullet yeah I don't want to stop you sliding down unfortunately it'll make that worse for me but we have tests that we can do I've got more horrible tests you know you had the end eye upper gi endoscopy I've there's a test we could do where we measure the acid exposure in your lower gullet you have that for 24 hours you have a tube in your nose measuring the acid in your gullet and then with that data we can tell you whether your esophagus is very sensitive to acid or whether your stomach is producing an excess of acid and that's washing up on your guttlet usually the reason sorry go on yes celiac disease yep okay have you been tested for that yeah yeah of course I can't see that in the last year at least you've been tested for celiac disease in your blood tests certainly your duodenum the first part of the small intestine which celiac disease most commonly affects looked entirely normal but we know that sometimes that's not the best test for it I can send you out some blood tests to look for whether you have celiac disease it'd be very it's a trivial test to do well why don't we test you for celiac disease that sounds entirely sensible I'll send out some yeah no why not I'll send out some blood tests for you if that's okay which you can have done at the hospital or at windsor house or with your gp to just make sure that you don't have celiac disease and that's very easy to do isn't it I think like I said I think we've got horrible tests we can do but usually the goal of those tests is to think about whether someone might need an operation for bad reflux but I wouldn't I I think it's quite a significant undertaking an operation I think the recovery would be quite significant exactly yeah and being yeah I mean I think reasonably being 82 we know that we are gonna make things worse probably so it's best not to probably I would think and to try those lifestyle changes switching to gaviscon double action raising the head of the bed as much as you can we'll test you for cvf disease and make sure you don't have that and I think a combination of those things will really help I and and I think we should we should take it from there we've always got the option where you can do that test in the future but for now try those things is that alright brilliant great I'll send out the blood test for you look forward to seeing the results try the gaviscon try lifting the head of the bed and and then in terms of seeing you again I think those things will work why don't I enroll you into patient initiated follow-up for a year you can call our secretaries or call our bookings office and we'll put you into our next free slot which usually happens you know a couple of weeks after you call instead of planning to follow you up again in 6 months I think this will sort everything out and so we won't need to plan to see you again but if you want to see us again we'd be more than happy to chat to you just call secretaries up again does that sound alright brilliant brilliant great so you'll get a letter from me and get the blood test done that I that I've suggested you can you don't need an appointment you can walk in to get them done at windsor house which is in near near derriford or you can ask your gp to be booked in for some bloods because your your influenza is not too bad and then try the gaviscon double action and try yeah and try the raising the head of the bed slightly wonderful alright then nice to talk to you no worries talk talk to you soon bye bye so it's a clinical letter for pauline jones plan number 1 blood tests including ttg 2 patient issued follow-up for 12 months number 3 trial of gaviscon double action number 4 trial of raising the head of the bed number 5 if persistent symptoms despite lifestyle measures consider ph manometry however operative management of well don't write that just consider ph and manometry did you hear I had the pleasure of catching up with missus jones on the telephone today on behalf of doctor klamova in gastroenterology clinic full stop <\n\n> I had the pleasure of meeting her in person at the time of her upper gi endoscopy and we were able to talk through the results of this full stop <\n\n> She has a diagnosis of colitis which was managed surgically and reassuringly she doesn't have any discharge or pain in her rectal stump she finds that her ileostomy works fine although it's slightly sore on her skin and does tend to be most active at night full stop she'll empty her bag 3 times in a 24 hour. And change the bag every 2 days full stop she doesn't get any symptoms from a high output stoma in terms of muscle cramps or excessive thirst <\n\n> She does unfortunately still suffer with symptoms of heartburn with pronounced erection which describes the burning pain behind her breastbone symptoms mainly affect her at night where she sleeps with 2 pillows it can affect her during the day as well full stop <\n\n> I explained that hiatus hernia at the time of her which we found at the time of her upper gi endoscopy is most likely causing her symptoms at night where acid can easily wash up over the lower gullet and the samples taken from her lower gullet demonstrate that although there's no evidence of barrett's or any other worrying changes there are signs of acid reflux here full stop paragraph we discussed the potential of undertaking ph and manometry studies to investigate the character and volume amount of her reflux further however it's an invasive test and I don't think operative management would be considered in this lady's care so we've elected to not undertake this today full stop <\n\n> Her daughter's recently been diagnosed with celiac disease and she was also suffering with erectation prior to this and so I offered a test of her cfcs with some blood tests which she could have performed at windsor house at her convenience I've advised her to try gaviscon double action which can be beneficial in troublesome reflux and also to raise the head of her bed slightly with bricks or books to try to keep acid in her stomach as much as possible full stop paragraph I've enrolled her into patient initiated follow-up for 12 months she's more than welcome to get in contact with us if she wants to see us again you're sincerely