【Case 02】Gastroesophageal Reflux Disease (Reflux Esophagitis Grade LA-B)

📋 Basic Information

• Medical Record No.: SS-2025-NK-002

• Patient Information: Ms. Emma, British, Female, 45, Architectural Designer

• Treatment Cycle: 8 weeks

Diagnostic Information

• Chief Complaint: Recurrent acid regurgitation and heartburn for 4 years, aggravated with retrosternal pain for 1 month

• Present Illness: The patient developed acid regurgitation and heartburn 4 years ago due to long-term night shifts and 3-4 cups of coffee daily, worsening after meals and when lying down. One month ago, symptoms aggravated after consecutive overnight work, with 3-4 daily regurgitation episodes, retrosternal burning, foreign body sensation in throat, and occasional nocturnal choking. External gastroscopy showed reflux esophagitis (LA-B grade) with 3 longitudinal mucosal erosions in distal esophagus.

• Western Diagnosis: Gastroesophageal reflux disease; Reflux esophagitis (Grade LA-B)

• TCM Diagnosis: Acid regurgitation disorder (Liver-stomach stagnated heat with adverse rising of stomach Qi)

💊 Comprehensive Treatment Plan

Visceral Tuina + thoracic adjustment twice weekly; acupuncture 3 times weekly; ultrasonic drug penetration daily; diaphragm biofeedback training twice daily; modified Zuojin Pill + Xuanfu Daizhe Decoction 1 dose/day for 8 weeks.

📊 Efficacy Assessment Indicators

✅ Efficacy Evaluation