A 42-year-old woman comes to the office due to increasing heartburn and regurgitation over the last 2 years. Previously her symptoms only occurred after a large meal, but recently they have occurred almost daily. She has had no dysphagia, odynophagia, weight loss, hematemesis, or melena. The patient has no other medical issues and takes no medications. She smokes cigarettes and drinks alcohol, although she has been cutting back on both. The patient is a paralegal and describes her work as stressful. Vital signs are within normal limits. BMI is 28 kg/m². The abdomen is nondistended, soft, and nontender with no hepatosplenomegaly. The remainder of the physical examination is unremarkable and fecal occult blood testing is negative. The patient says her symptoms are starting to affect her life and would like them to be controlled. Which of the following is the most appropriate response to the patient regarding the next step in management?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf36_c204_8f63_45264bfe006f_MD0005_00 This patient's heartburn and sensation of regurgitation are consistent with gastroesophageal reflux disease (GERD). In patients with frequent GERD symptoms (eg, >2 times per week) and no alarm signs or symptoms (eg, dysphagia, odynophagia, anorexia, weight loss, evidence of gastrointestinal bleeding), initial treatment is recommended with a daily proton pump inhibitor (PPI) (eg, omeprazole) for at least 8 weeks. Lifestyle changes (eg, smoking cessation, alcohol reduction) should be pursued as well. Such a patient whose symptoms fail to improve with an 8-week trial of low-dose (daily) PPI therapy should generally increase to high-dose (twice daily) PPI therapy for at least 8 weeks prior to any further investigation or intervention. In patients with mild or infrequent GERD symptoms (and no alarm signs or symptoms), initial therapy with an as-needed histamine-2 receptor blocker (eg, ranitidine) is recommended in combination with lifestyle changes; subsequent step-up to PPI therapy can be performed if needed. (Choice A) Right upper quadrant ultrasound can be used to assist in the diagnosis of biliary colic due to gallstone disease. However, patients typically have postprandial, colicky right upper quadrant abdominal pain rather than sensation of heartburn and reflux. (Choice B) Esophageal pH monitoring is indicated in patients with persistent GERD symptoms despite at least 8 weeks of high-dose PPI therapy, but it is typically not performed prior to an adequate medication trial. (Choice C) Referral to a gastroenterologist for esophagogastroduodenoscopy (EGD) is indicated in patients who have alarm signs or symptoms at presentation, or who have failed at least 8 weeks of both low- and high-dose PPI therapy. Previously, EGD was recommended in any patient age >50 presenting with GERD symptoms, but the diagnostic yield of EGD appears low in patients of any age who lack alarm signs or symptoms. (Choice D) Surgery (eg, Nissen fundoplication) is an option in patients whose GERD symptoms demonstrate only partial response to high-dose PPI therapy. However, it should not be considered prior to an adequate trial of lifestyle modification and medication therapy. Educational objective: Patients presenting with symptoms of gastroesophageal reflux disease (eg, heartburn, reflux, cough) and no alarm signs or symptoms (eg, dysphagia, odynophagia, weight loss, signs of gastrointestinal bleeding) should be initially managed with lifestyle modification and a trial of medication therapy. Initial treatment with a daily proton pump inhibitor (eg, omeprazole) for at least 8 weeks is recommended in patients with frequent symptoms. References: An evidence-based approach to the treatment of gastroesophageal reflux disease. (http://www.ncbi.nlm.nih.gov/pubmed/26629969) Upper GI tract findings in patients with heartburn in whom proton pump inhibitor treatment failed versus those not receiving antireflux treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19922918)

A 42-Year-Old Woman Comes to the Office Due to Increasing