Case Study: 45-Year Old Woman With Reflux and Stomach Aches
It’s time for another case study again today! Last time I told you about my client Vanessa, a 24-year old woman with bloating and stomach aches. And today I’d like to shine a light on Melissa, a 45-year old woman with stomach acid reflux and stomach aches. By sharing Melissa’s story, I expect to give you more insight into possible solutions to reduce IBS-symptoms.
The information on Positive Gut is for informational purposes only. The information is not meant to be a substitute for professional medical advice, diagnosis or treatment. If you have any concerns about your health, always seek the advice of your doctor.
Who is Melissa?
For the purpose of this case study, I will call my client Melissa. This is not her real name.
Melissa first contacted me through my online dietitian practice in May 2020. We were in the middle of the Corona lockdown in the Netherlands, so the online practice was an ideal way to keep helping clients.
She was 45 years old, and had been dealing with daily symptoms of stomach aches and acid reflux for about 2 months now.
She had never experienced any digestive issues in the past and was very worried about this onset of her symptoms. Melissa had talked to her GP, and was assured that is was nothing worrisome, but she could try and see a gut health dietitian. And that’s how she found me!
My First Consultation With Melissa
My first consultation with Melissa was on a late wednesday afternoon. She had filled in my preparatory questionnaire and had kept a food and symptoms diary for the 4 days prior our call. This was going to be the lead to start our conversation from.
We started with a thorough conversation about her symptoms. Melissa told me she had had her symptoms for about 2 months now, and it had started very suddenly with an intense and short pain in her stomach after dinner with friends. The intense pain never came back, but Melissa was now left with daily stomach acid reflux and stomach aches.
Melissa’s stools were diarrhea like, and she had stools 1-2x a day of type 5-6 of the Bristol Stool Chart (see image below). During our conversation, it also became clear that her gallbladder had been removed 15 years ago. This could be a factor that is contributing to symptoms and soft stools now.
In the last couple of weeks Melissa had tried some over the counter stomach acid medication to ease her symptoms and had started taking a magnesium supplement to reduce muscle cramps.
Her whole life Melissa had been Jojo-dieting and since a couple of years, she had accepted her body weight and was focusing on keeping that stable.
She lived with her husband and kids and worked 3 mornings a week.
Melissa’s main goal for our consultations was to find out what the triggers were for her symptoms and to find out how to manage it properly.
The Food and Symptoms Diary
After Melissa and I had thoroughly discussed her symptoms and lifestyle, we discussed her food and symptoms diary. She had tracked 5 days before the consultation in the diary format I had sent her. And I asked additional questions about her eating habits.
A couple of things stood out to me:
– Melissa was drinking with her meals.
– She did not eat enough fiber.
– She often used high sugar products.
– Her food intake was not as regular as it ideally should be.
– She tried to keep her fat intake low, because it triggered symptoms.
That provided plenty of opportunity for improvement! I gave Melissa a summary of my findings and we continued on to the plan.
The Diet Plan
Based on Melissa’s eating habits, supplement intake and food pattern we created a plan. It came down to this:
Replace the magnesium for a proper absorbable magnesium variety.
No drinking 30-minutes before and after meals. To help support digestion.
Increasing the fiber intake. To improve the stool consistency and support the microbiome.
Creating regularity. Having a regular food pattern with smaller meals over the day makes it easier to digest.
I put everything in writing for Melissa, and created a custom meal plan as an example. She was getting started straight away!
Are you suffering from IBS symptoms like stomach acid reflux, stomach aches or loose stools? I can help!
The Follow-up Consultations
During our first follow up consultation. Melissa told me she was already feeling a lot better! She had had a couple of days that weren’t too great, but her symptoms hadn’t been there every day. Even though she had some difficulties to keep a regular schedule and keep food and drinks separate, she did change her Magnesium supplement and ate more regularly and fiber-rich than before.
Melissa mentioned that she still had some stomach aches sometimes and that the reflux sometimes woke her up in the night. She mentioned that she sleeps on her belly and this may be worsening her symptoms.
We adjusted the plan, she was going to keep working on the plan we already made, but she was going to drink some peppermint and ginger tea at night to help relieve symptoms. She could also take a herbal supplement if her symptoms were really bad and was going to lift the top of her matress to make sure her head wasn’t lower than her stomach when she sleeps.
During our second follow up consultation Melissa was super happy! She hadn’t had any stomach aches anymore, and very rarely she felt stomach acid reflux. The reflux could always be linked to a super fatty meal, which is a trigger for stomach acid for most people. So that was nothing too bad.
Her bowel movements had normalized and she started baking to make herself fiber-rich snacks.
At this point, Melissa didn’t have any more questions and felt like she knew everything she needed to know to live her life without symptoms. We decided not to schedule any more follow up consultations and Melissa could always contact me if she had more questions.
For Melissa, the solution for her symptoms lay in some small adjustments in her eating habits and supplement intake, combined with a more fiber-rich diet.
Sometimes symptoms can show up out of nowhere because the gut can get less resilient over time. An unbalanced food pattern or eating habits after gallbladder removal might cause no problems for years but it can start causing problems as you age.
Looking for symptom relief from IBS? I’ll show you step by step how to take control of bloating, stomach pain and constipation. Book a free assessment call to learn more.
Hi there, I’m Manon.
In my daily life I work as a registered dietitian in the Netherlands with a special interest in gut health.
During my workday I get loads of questions about healthy food, recipes and lifestyle to make it a little easier to get healthy. On Positive Gut I collect my best recommendations, tips and recipes to make your healthy lifestyle a little easier!