Case Study: Gastroesophageal Reflux, Persistent Throat Phlegm, and Post-Breakfast Fatigue – A Traditional Chinese Medicine Approach
Real clinical cases 02 Jun 2026

Case Study: Gastroesophageal Reflux, Persistent Throat Phlegm, and Post-Breakfast Fatigue – A Traditional Chinese Medicine Approach

A 71-year-old patient came to my clinic with three main complaints that were significantly affecting his quality of life:

 

A constant sensation of phlegm in the throat that had persisted for a long time and had not improved despite various approaches.

 

Frequent gastroesophageal reflux.

 

Extreme fatigue after breakfast, severe enough to limit his activities for much of the morning.

 

Apart from these symptoms, the patient was in excellent overall health. Multiple blood tests, medical examinations, and diagnostic investigations performed over the years had all produced normal results. No underlying organic disease could be identified to explain the severity of his symptoms.

 

Assessment According to Traditional Chinese Medicine

 

From the perspective of Traditional Chinese Medicine (TCM), symptoms are not viewed in isolation but as manifestations of an underlying functional imbalance within the body.

 

Following a comprehensive assessment, including detailed history taking and evaluation according to TCM principles, the patient's presentation was consistent with a deficiency of Spleen Qi.

 

In Traditional Chinese Medicine, the Spleen plays a central role in transforming food into energy and nutrients. When Spleen Qi becomes weakened:

 

Digestion becomes less efficient.

 

Fatigue may occur after meals.

 

Internal dampness can accumulate.

 

Dampness may transform into phlegm.

 

Phlegm can rise and manifest as persistent mucus or a sensation of phlegm in the throat.

 

The normal descending function of the Stomach may become impaired, contributing to reflux symptoms.

 

From this perspective, the throat phlegm was not considered the primary problem but rather a manifestation of a deeper digestive and energetic imbalance.

 

Treatment Plan

 

A course of acupuncture was initiated, consisting of one session per week for six consecutive weeks.

 

The main therapeutic goals were:

 

Tonify and strengthen Spleen Qi.

 

Support digestive function.

 

Reduce the formation of dampness and phlegm.

 

Restore the normal downward movement of Stomach Qi.

 

Improve the patient's overall energy and vitality.

 

Acupuncture points were selected individually at each session according to the patient's presentation and progress.

 

Nutritional Recommendations Based on Traditional Chinese Medicine

 

Dietary therapy played a key role in the treatment strategy.

 

For patients presenting with Spleen Qi deficiency, Traditional Chinese Medicine generally recommends warm, cooked, and easily digestible foods.

 

Recommended Foods

 

Cooked Grains

 

Brown rice

 

White rice

 

Millet

 

Cooked oats

 

Quinoa

 

Buckwheat

 

Cooked Vegetables

 

Pumpkin

 

Carrots

 

Sweet potatoes

 

Zucchini

 

Parsnips

 

Fennel

 

Green beans

 

Leeks

 

Protein Sources

 

White fish

 

Oily fish in moderation

 

Chicken

 

Turkey

 

Eggs

 

Well-cooked legumes

 

Red lentils

 

Chickpeas

 

Soups and Broths

 

Vegetable broths

 

Chicken soups

 

Vegetable soups

 

Slow-cooked stews

 

Foods Traditionally Used to Strengthen Spleen Qi

 

Chinese red dates (jujubes)

 

Chestnuts

 

Pumpkin

 

Sweet potatoes

 

Oats

 

Millet

 

Foods to Reduce or Avoid Temporarily

 

Cold Foods and Drinks

 

Iced beverages

 

Cold soft drinks

 

Ice cream

 

Excessive Raw Foods

 

Large raw salads

 

Cold smoothies

 

Chilled fruit juices

 

Foods That Promote Dampness

 

Excess dairy products

 

Pastries and baked sweets

 

Refined sugar

 

Processed foods

 

Highly refined carbohydrates

 

Foods That May Aggravate Reflux

 

Alcohol

 

Excessive coffee consumption

 

Very spicy foods

 

Fried foods

 

Eating Habits

 

The patient was also advised to:

 

Eat warm and nourishing breakfasts.

 

Eat slowly and mindfully.

 

Chew food thoroughly.

 

Avoid large evening meals.

 

Maintain regular meal times.

 

Outcome

 

After six weeks of acupuncture treatment combined with dietary modifications:

 

The persistent sensation of phlegm in the throat completely resolved.

 

Gastroesophageal reflux symptoms disappeared.

 

The extreme fatigue experienced after breakfast was no longer present.

 

The patient reported stable energy levels throughout the morning.

 

Overall well-being and quality of life improved significantly.

 

Final Reflections

 

This case illustrates how symptoms that may appear unrelated can be understood as part of a single functional pattern within the framework of Traditional Chinese Medicine. By addressing the underlying imbalance through acupuncture and individualized dietary therapy, it was possible to support the patient's recovery and improve his daily functioning.

 

As with all case reports, this represents the experience of one individual and should not be interpreted as proof of treatment effectiveness. Nevertheless, it provides an interesting example of how an integrative approach may help address persistent digestive and functional symptoms in selected patients.