A 63-year-old female visited Toho University Omori Hospital with complaints of heartburn and persistent laryngeal discomfort. She received an endoscopic examination two years ago as a further examination of gastric cancer screening. At that time, atrophic gastritis was pointed out and Helicobacter pylori (H.pylori) infection was positive. Although H.pylori was successfully treated with a PPI-based triple therapy, laryngeal discomfort had not been disappeared. First, an upper endoscopic examination was performed, but abnormal findings of the esophagus, including a mucosal break, hiatal hernia, and whitish mucosa, were not detected (Fig. 1). Therefore, saliva scintigraphy was performed to evaluate the salivary function. In our previous study, we defined the optimal cutoff point for determining the decreased salivary secretion as 51% in parotid glands and 36% in submandibular glands.
After an overnight fasting, saliva scintigraphy was performed with the patient in the supine position under a gamma camera with high-resolution collimators. No oral stimulus was permitted before and during imaging. Following intravenous injection of 180 to 200 Mbq 99 mTc-pertechnetate, anterior sequential imaging was performed every minute for 40 minutes. At 20 minutes after injection of radio-nuclide, a lemon candy was administrated intraorally to stimulate salivary secretion. Regions of Interests (ROI) were selected on the individual submandibular and parotid glands, oral cavity, and thyroid gland. Time activity curves were drawn for each of these. Washout ratio (peak count before lemon candy administration-lowest count after administration/peak count before administration) was examined.
Washout ratio was 40% in the right parotid gland, 25% in the left parotid gland, 25% in the right submandibular gland, and 30% in the left submandibular gland (Fig. 1). After the first scintigraphy was performed, the patient received 300 mg of nizatidine per day for 2 months based on the treatment for peptic ulcer in Japan. During the two months course of the nizatidine treatment, the patients has not taken any other drugs and there have no possible confounding factors that would also change salivary flow. After the treatment, salivary scintigraphy was done and demonstrated the increased washout ratios in all four major glands (Fig. 2). The value of right parotid gland increased from 40% to 80% and that of left one did from 25% to 78% after treatment with nizatidine. Likewise, the washout ratio of right submandibular gland increased from 25% to 45% and that of left one did from 30% to 51%. GERD symptoms, including heartburn and laryngeal discomfort disappeared completely after treatment. The patient has been followed up for 10 months after nizatidine treatment and GERD symptoms have not reappeared.