A 54-year-old man comes to the clinic complaining of bitter taste and substernal burning 30-40 minutes after meals. The burning is relieved with antacids and worsened by lying supine. He has also noticed that food gets stuck in his chest if he does not chew properly. He has had an unintentional weight loss of 4.5 kg (10 lb) over the past 3 months. The patient has a 40-pack-year smoking history. He has no family history of cancer. He is afebrile with stable vital signs. The physical examination is unremarkable. Chest x-ray and electrocardiogram show no abnormalities. The stool guaiac test is negative. Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old man comes to the clinic complaining of bitter taste and substernal burning 30-40 minutes after meals.  The burning is relieved with antacids and worsened by lying supine.  He has also noticed that food gets stuck in his chest if he does not chew properly.  He has had an unintentional weight loss of 4.5 kg (10 lb) over the past 3 months.  The patient has a 40-pack-year smoking history.  He has no family history of cancer.  He is afebrile with stable vital signs.  The physical examination is unremarkable.  Chest x-ray and electrocardiogram show no abnormalities.  The stool guaiac test is negative.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d2e1_730e_bc81_fd823630a19f_MD0003_00 This patient's presentation is consistent with typical gastroesophageal reflux disease (GERD). Patients with typical GERD require upper gastrointestinal (GI) endoscopy if they have alarm symptoms (dysphagia, odynophagia, weight loss, anemia, GI bleeding, or recurrent vomiting) or are men age >50 with chronic (>5 years) symptoms and cancer risk factors (eg, tobacco use). Patients with esophagitis on endoscopy can receive treatment depending on the diagnosis (eg, autoimmune disease, Barrett's esophagus). Patients without esophagitis on endoscopy usually require further evaluation (eg, esophageal manometry). Patients with typical GERD symptoms who do not meet initial endoscopy criteria can receive an initial trial of daily proton pump inhibitor (PPI). Patients with refractory symptoms should try another PPI or increase the use of PPI to twice daily. Patients with persistent symptoms likely require further testing such as endoscopy or esophageal pH monitoring. This patient's presentation (age >50, unintentional weight loss, dysphagia, tobacco use) warrants initial endoscopy (rather than PPI or H2 blockers) to assess for complications of GERD (Choices D and E). (Choices A and B) Esophageal manometry and pH monitoring should be considered in patients with persistent GERD symptoms or normal upper GI endoscopy to assess for other conditions (eg, motility disorders) that can occasionally mimic GERD. (Choice C) Helicobacter pylori can cause gastric and duodenal ulcers. Testing is indicated in patients with active or past history of peptic ulcer disease. Routine screening and empiric treatment for H pylori infection may also be considered for patients who have dyspepsia but not GERD. Educational objective: Patients with typical gastroesophageal reflux symptoms require an upper gastrointestinal (GI) endoscopy if they have alarm symptoms (dysphagia, odynophagia, weight loss, anemia, GI bleeding, or recurrent vomiting) or are men age >50 with chronic (>5 years) symptoms and cancer risk factors (eg, tobacco use). All other patients can receive an empiric trial of proton pump inhibitor therapy and further evaluation if refractory to therapy. References: Guidelines for the diagnosis and management of gastroesophageal reflux disease. (http://www.ncbi.nlm.nih.gov/pubmed/23419381) Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. (http://www.ncbi.nlm.nih.gov/pubmed/23208168)

A 54-Year-Old Man Comes to the Clinic Complaining of Bitter