A 35-year-old man is evaluated for heartburn and a sour taste in his mouth. The patient initially presented 2 months ago due to these symptoms, and a proton pump inhibitor was begun. He has had mild relief but continues to have bothersome symptoms after his evening meal. The patient has avoided drinking coffee and eating fatty or spicy foods, and he eats his evening meal at least 2 hours before bedtime. He has had no weight loss, abdominal pain, nausea, vomiting, or black or tarry stools. The patient has no other medical issues; his only medication is lansoprazole, which he takes 30 minutes before breakfast. He works in a bank and does not use tobacco, alcohol, or illicit drugs. His father was diagnosed with colon cancer at age 67.
Vital signs are within normal limits. BMI is 28 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 35-year-old man is evaluated for heartburn and a sour taste in his mouth. The patient initially presented 2 months ago due to these symptoms, and a proton pump inhibitor was begun. He has had mild relief but continues to have bothersome symptoms after his evening meal. The patient has avoided drinking coffee and eating fatty or spicy foods, and he eats his evening meal at least 2 hours before bedtime. He has had no weight loss, abdominal pain, nausea, vomiting, or black or tarry stools. The patient has no other medical issues; his only medication is lansoprazole, which he takes 30 minutes before breakfast. He works in a bank and does not use tobacco, alcohol, or illicit drugs. His father was diagnosed with colon cancer at age 67.
Vital signs are within normal limits. BMI is 28 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:

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

Quizplus · Accepted Answer

This patient has gastroesophageal reflux disease (GERD) symptoms (ie, heartburn, regurgitation) refractory to once-daily proton pump inhibitor (PPI), which occurs in 10%-40% of patients. GERD is usually treated first with lifestyle modifications (eg, smoking and alcohol cessation, weight loss, decreased caffeine intake) and medical therapy such as histamine 2-blocker or PPI. Patients with persistent symptoms on a daily PPI should either switch to a different PPI or maximize therapy with a twice-daily PPI. However, the preferred approach is twice-daily PPI, as changing to a different PPI provides minimal benefit in most cases. Gastroenterology referral should also be considered in these patients. (Choice A) Esophageal pH monitoring and impedance testing should be considered in patients with GERD symptoms that do not respond to 4-8 weeks of twice-daily PPI therapy; however, these are not indicated in those with persistent symptoms on once-daily PPI therapy. (Choice B) Once-daily PPI therapy achieves optimal 24-hour acid suppression when given 30 minutes prior to the first meal of the day following a prolonged fast (ie, breakfast for most patients). Therefore, changing this patient's lansoprazole administration from morning to evening is likely to result in an overall worsening of GERD symptoms. (Choice D) Upper gastrointestinal endoscopy is indicated prior to initiating once-daily PPI or increasing to twice-daily PPI in patients with GERD and unexplained alarm features (eg, weight loss, gastrointestinal bleeding, dysphagia, odynophagia). However, in the absence of alarm features, endoscopy is not indicated prior to failure of 4-8 weeks of twice-daily PPI therapy. (Choice E) Although there is a clear role for Helicobacter pylori testing and eradication in patients with dyspepsia (ie, postprandial fullness, early satiety, epigastric pain), the test-and-treat approach does not have a clear role in the management of GERD. Educational objective: Patients with gastroesophageal reflux disease symptoms that are refractory to once-daily proton pump inhibitor (PPI) therapy should increase to twice-daily PPI therapy. In the absence of unexplained alarm symptoms, upper endoscopy is not indicated prior to failure of 4-8 weeks of twice-daily PPI therapy. __________ References: Refractory gastroesophageal reflux disease. (http://www.ncbi.nlm.nih.gov/pubmed/25274499)

A 35-Year-Old Man Is Evaluated for Heartburn and a Sour