An 18-year-old man comes to the emergency department due to retrosternal chest pain and pain with swallowing. The patient has a burning pain that began abruptly the previous morning and then gradually worsened. He has been limiting himself to soft foods as the pain is much worse with swallowing solids. The patient has a history of tension headaches that have become more frequent lately, which he attributes to long hours of studying for exams. His only medication is ibuprofen as needed for headaches, and he has no drug allergies. The patient's mother has Crohn disease. He drinks alcohol socially, smokes a half pack of cigarettes daily, and does not use illicit drugs. The patient is sexually active and uses condoms inconsistently.
Temperature is 36.7 C (98.1 F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min. There are no oropharyngeal lesions or palpable lymphadenopathy. The lung auscultation and cardiac examination are normal. The abdomen is soft without rebound or guarding.
Which of the following is the most appropriate next step in management of this patient's symptoms?

Question

An 18-year-old man comes to the emergency department due to retrosternal chest pain and pain with swallowing.  The patient has a burning pain that began abruptly the previous morning and then gradually worsened.  He has been limiting himself to soft foods as the pain is much worse with swallowing solids.  The patient has a history of tension headaches that have become more frequent lately, which he attributes to long hours of studying for exams.  His only medication is ibuprofen as needed for headaches, and he has no drug allergies.  The patient's mother has Crohn disease.  He drinks alcohol socially, smokes a half pack of cigarettes daily, and does not use illicit drugs.  The patient is sexually active and uses condoms inconsistently.
Temperature is 36.7 C (98.1 F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min.  There are no oropharyngeal lesions or palpable lymphadenopathy.  The lung auscultation and cardiac examination are normal.  The abdomen is soft without rebound or guarding.
Which of the following is the most appropriate next step in management of this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_9613_a49b_853d_a18a68c92bf1_MD0002_00 This patient with acute substernal chest pain and odynophagia associated with ibuprofen use likely has medication-induced esophagitis (MIE). MIE is due to direct mucosal injury, typically occurring when a pill becomes lodged at a narrow point in the esophagus. Risk factors include abnormal esophageal anatomy, large pill size, pill ingestion while supine, and inadequate fluid intake. Common offending medications include nonsteroidal anti-inflammatory drugs, bisphosphonates, potassium chloride, iron supplements, and tetracyclines. Treatment of MIE includes discontinuation of the offending medication and supportive measures (eg, fluids, pain control) as needed. Some experts also advise a trial of a proton pump inhibitor or sucralfate. Upper endoscopy is indicated in patients with severe or atypical symptoms (eg, hematemesis, weight loss) or those who continue to have symptoms 1 week after drug withdrawal to evaluate for stricture or secondary causes (Choice E). Patients who need to take a potentially offending medication should be instructed to take it with at least 8 oz of water and remain upright for at least 30 minutes after ingestion. (Choice A) Barium esophagram can be used to diagnose anatomic abnormalities and neuromuscular disorders (eg, achalasia); however, it has limited diagnostic value in MIE unless there is concern for extrinsic compression leading to pill retention. (Choice B) The most common cause of HIV-associated odynophagia is Candida esophagitis. However, this condition is usually associated with dysphagia and oral thrush. HIV testing should be offered to any patient with high-risk sexual activity, but it is unlikely to affect management in this case. (Choice C) Eosinophilic esophagitis can cause chest pain and heartburn. It is treated primarily with dietary restrictions, although swallowing an inhaled fluticasone spray can be considered as second-line therapy. However, eosinophilic esophagitis often presents with dysphagia, and this patient's frequent ibuprofen ingestion and odynophagia make MIE more likely. Educational objective: Medication-induced esophagitis is due to direct mucosal injury and is frequently noted with nonsteroidal anti-inflammatory drugs, tetracyclines, bisphosphonates, iron supplements, and potassium chloride. Discontinuation of the offending medication is usually adequate treatment, but additional evaluation is indicated for patients with severe, atypical, or persistent symptoms. __________ References: Clinical and endoscopic characteristics of drug-induced esophagitis. (http://www.ncbi.nlm.nih.gov/pubmed/25152603)

An 18-Year-Old Man Comes to the Emergency Department Due to Retrosternal