A 42-year-old man comes to the office because of heartburn. He has had these symptoms for the past 3 months. He states that symptoms occur almost daily and he has experienced nocturnal awakening because of regurgitation at least twice weekly. This has caused him daytime fatigue and poor concentration at work. He also complains of dry cough and wheezing. He denies any difficulty swallowing, nausea, vomiting, or weight loss. He has tried over-the-counter antacids with no significant relief.
His other medical problems include hypertension and mild intermittent asthma. He does not use tobacco, alcohol, or drugs. His father suffered from colon cancer at the age of 68 and his mother died of breast cancer at the age of 72. His medications include hydrochlorothiazide and lisinopril. He uses albuterol as needed for shortness of breath. He has no known drug allergies.
His blood pressure is 138/89 mm Hg and pulse is 87 /min. His BMI is 30 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Question

A 42-year-old man comes to the office because of heartburn. He has had these symptoms for the past 3 months. He states that symptoms occur almost daily and he has experienced nocturnal awakening because of regurgitation at least twice weekly. This has caused him daytime fatigue and poor concentration at work. He also complains of dry cough and wheezing. He denies any difficulty swallowing, nausea, vomiting, or weight loss. He has tried over-the-counter antacids with no significant relief.
His other medical problems include hypertension and mild intermittent asthma. He does not use tobacco, alcohol, or drugs. His father suffered from colon cancer at the age of 68 and his mother died of breast cancer at the age of 72. His medications include hydrochlorothiazide and lisinopril. He uses albuterol as needed for shortness of breath. He has no known drug allergies.
His blood pressure is 138/89 mm Hg and pulse is 87 /min. His BMI is 30 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_97ef_df64_853d_dd6e2ec2d336_MD0002_00 This patient presents with new-onset symptoms of gastroesophageal reflux disease (GERD), including some extra-esophageal symptoms (dry cough and wheezing). Patients with GERD typically present with retrosternal burning pain but can also have acid regurgitation, belching, nausea, dry cough (especially at night), and a feeling of a lump in the throat with swallowing. Current guidelines recommend empiric treatment with a proton pump inhibitor (e.g. omeprazole) and lifestyle changes in most patients. Patients who fail empiric treatment require further evaluation with endoscopy. However, patients with alarm symptoms (shown above) require more immediate evaluation with endoscopy. This patient does not have alarm symptoms but does have typical GERD symptoms and can be initially treated with a proton pump inhibitor. (Choice A) Barium swallow has low sensitivity for mild GERD and is usually not indicated for the evaluation of uncomplicated GERD. Barium swallow is more sensitive and specific to diagnose strictures in evaluating patients with dysphagia. (Choice B) Metoclopramide increases gastric motility but is currently not recommended as monotherapy or adjunctive therapy for GERD due to possible side effect of tardive dyskinesia. (Choice D) The respiratory symptoms of dry cough and wheezing occurred at the same time as the reflux symptoms and therefore, are most likely related. Pulmonary function testing is unnecessary and would be unlikely to yield any additional information at this time. (Choice E) There are currently no alarm symptoms requiring an urgent endoscopy. Also, EGD for Barrett's screening in reflux disease is usually done after a few years of symptoms (5 years or more) when the disease has been present long enough to cause mucosal changes. It will be premature at this time to look for Barrett's. Educational objective: Indications for more immediate endoscopy in gastro esophageal reflux disease (GERD) are based on alarm symptoms (i.e., age > 50 years, dysphagia, weight loss, anemia, hematemesis/melena). In the absence of these alarm symptoms, a simple trial of proton pump inhibitors (omeprazole) is recommended. __________ References: Medical management of patients with esophageal or supraesophageal gastroesophageal reflux disease (http://www.ncbi.nlm.nih.gov/pubmed/12928099)

A 42-Year-Old Man Comes to the Office Because of Heartburn