“GERD/ Acid Reflux” Case Study

This case reviews of  60 year old male who was treated at Oakland Hills Acupuncture for GERD or “Acid Reflux”. The patient was treated mainly with Chinese herbs.  

Brief Synopsis Of Initial Examination/Interview

The patient reports a 5 year history of GERD or  Acid Reflux treated by his primary care physician (PCP) with Omeprazole.  The patient came to the visit desiring to come off of Omeprazole, which he had taken for five years. The prescribing physician was aware of the patient’s intention to stop Omeprazole. 

The patient stated that he “suffered a burning sensation” in his stomach when he did not take Omeprazole. On occasion, he stated felt burning in his throat in the mornings only. The patient also reported being unable to eat or drink acidic foods without pain.   

Upon inquiry the patient reports a long history of a high stress and fast paced lifestyle which he had only recently started to change. The patient denies belching, constipation, or loose stools.

Tongue: Large, Puffy, Scalloped, White coat – peeled and raw near tip.

Pulse: Wiry, Moderate force and rate. Deep and weak in 3rd positions.

Diagnosis & Treatment Plan

Dx: Wood overacting on  Earth (Chronic Liver Qi Stagnation leading to Spleen Qi deficiency and Stomach/Heart Yin deficiency) – explanation below

Txt Plan: Tonify Spleen/Stomach Qi and Yin, Regulate Liver and Stomach Qi, Clear heat as necessary.

The diagnosis here simply refers to chronic stress and pent up emotions leading to a lack of peristalsis in the digestive tract allowing for acid to build up and eventually wear at the lining in the upper Stomach and esophagus. The treatment was aimed at absorbing acid (in the short term), strengthening the digestive organs, restoring proper peristalsis, and assist in the healing of the lining of the digestive tract. 

The patient was told that after he stopped Omeprazole to expect some level of rebound acid reflux within first 2 weeks, address as needed.

The patient purchased granulated herb extracts, 1g of granules is equivalent to 5g of raw herb (5:1) unless otherwise noted in parentheses. Enough granules were provided for 6 days. The daily dosage was 12g of granules, with the patient instructed to take 6g twice daily in hot water. Daily Dosage of granulated herb extracts is as follows:

Hai Piao Xiao            3g

Dang Shen            1.25g

Bai Zhu                 1.25g

Shan Yao                   2g

Mai Men Dong          2g

Fo Shou                  1.5g

Zhi Gan Cao              1g

This roughly equals 60g of raw herb tea per day. 

Results & Follow-Up Visits
Visit 2

After 7 days the patient reported no incidence of Acid Reflux after eating . However, the past two days he reported some burning upon waking. The patient also reports that his bowel movements seemed to have become more regular.

The patient was given a refill for two weeks to be taken 6 grams(scoops), 2 x day. Minor reductions were made to some herbs and .5g of Huang Lian granules were added per day to address the burning in his throat.

Visit 3

After three weeks of treatment,  the patient reported very rarely having some brief and mild stomach pain that was “not really worth mentioning”. And he reported zero pain in his throat. He was given a refill, and Bai Zhu was switched to Chao Bai Zhu. This change was to better adjust the flow of Qi, or assist peristalis.

Visit 4 and Onward

The patient reported a continued absence of pain from GERD or Acid Reflux over the next few visits and continued taking the herbal formula. Over course of treatment, I reduced the dosages of Hai Piao Xiao and Huang Lian phased them out as symptoms stabilized as acid absorbtion and a reduction in the production of acid was no longer needed. 

After two months, the herbs had healed the peeled area of  the patient’s tongue coating. This part of his tongue no longer appeared raw although a mild indentation/scar was left behind by the peeling. In theory and practice this correlates with healing elsewhere in the body. The patient’s treatment lasted for 4 months during which he worked on developing better lifestyle choices to prevent a re-occurrence of GERD.

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