BMJ  2006;333:137 (15 July), doi:10.1136/bmj.333.7559.137

Commentary

A clinical challenge

¹ Department of Gastroenterology, King's Mill Hospital, Sutton-in-Ashton NG17 4JL robert.logan@nottingham.ac.uk

The first 150 words of the full text of this article appear below.

Several learning points arise from Mr Neville's case.¹ The most important relates to the diagnostic approach when we are challenged with pieces of a clinical puzzle that do not neatly fit together.

Gastro-oesophageal reflux disease usually poses few diagnostic challenges, especially when there is a good symptomatic response to empirical anti-secretory therapy. However, in this case, Mr Neville's poor response to treatment and persistent symptoms led to further investigation and several protracted stays in hospital. The normal oesophageal manometry and lower oesophageal sphincter pressures were an appropriate trigger for further investigations to eliminate underlying organic disease, especially distal obstructing lesions or intermittent torsion of a hiatus hernia (although symptoms are more typically episodic with a hernia).

As with difficult to diagnose diarrhoea, admission to hospital provided the main clue to the final correct functional diagnosis. The importance of the careful clinical observations made while Mr Neville was eating cannot be . . . [Full text of this article]

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