以胸痛表現之食道弛緩不能症案例報告

胸痛為臨床常見主述，在排除心因性問題後，常因病人合併胃灼熱感，診斷為胃食道逆流。然而本案例為一位36歲女性，因反覆進食後胸痛、胃灼熱及逆流等症狀，依醫囑斷續服用氫離子幫浦抑制劑（Proton Pump Inhibitor, PPI）治療胃食道逆流約一年仍未改善，直至夜間逆流咳嗽加劇，轉至本院消化內科求治，問診後發現合併有吞嚥困難及體重減輕情形，安排上消化道內視鏡排除食道腫瘤後，經食道攝影檢查確診為食道弛緩不能症（achalasia）。個案接受經口內視鏡肌層切開術治療、營養重建及心理諮商後，胸痛、逆流及吞嚥困難等症狀大幅改善，體重也從44 kg回復至50 kg，焦慮程度亦漸緩解。針對反覆出現與胃食道逆流相似症狀，或經藥物治療無效者，應進一步評估有無吞嚥困難，與胃食道逆流作鑑別診斷，避免病人因進食困難，造成營養不良併發症，以及長期睡眠困擾導致負向情緒感受，嚴重影響生活品質。  Chest pain as a relatively common clinical symptom especially when excluding ischemic heart dis­ease, patients are often diagnosed with gastroesophageal reflux disease due to acid regurgitation and a sensation of heartburn. A 36-year-old woman had had been intermittently treated with an oral proton pump inhibitor (PPI) under the impression of gastroesophageal reflux disease for approximately one year due to recurrent chest pain, heartburn, and a sensation of regurgitation. However, the symptoms deteriorated with exacerbation at night, which was an indication of poor response to the oral medi­cation. Thus, she was transferred to the Department of Gastroenterology for further examination and treatment. After detailed inquiry, the patient also suffered from progressive dysphagia with body weight loss, chest pain and regurgitation sensation. Therefore, an upper gastrointestinal panendoscopy was performed to exclude the presence of esophageal tumors. A diagnosis of esophageal achalasia was confirmed after an upper gastrointestinal examination series was conducted. After informing the patient, per-oral-endoscopic myotomy was performed. Nutritional supplementation and psychological consultation were also provided. The patient’s symptoms (e.g., chest pain, regurgitation, and dyspha­gia) improved significantly. Body weight increased from 44 kg to 50 kg, and her anxiety level was gradually reduced. For those who diagnosed with recurrent gastroesophageal reflux disease along with a poor response to oral medications, a detailed inquiry and a specific examination should be conduct­ed for other differential diagnoses, (e.g., achalasia) that may have long-term negative impact on the patient’s nutritional status, sleep disturbance, negative emotions, and quality of life