LEARNING OBJECTIVE
Apply current guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD).
QUESTION 1
A 65-year-old White man presents with symptoms of heartburn, regurgitation, and dysphagia for solid foods for 3 months. His symptoms occur 4–5 times a week and have increased recently. He reports eating a high-fat diet with frequent late-night snacks and caffeinated drinks due to long work hours and project deadlines. He drinks 1–2 beers/d. He does not smoke tobacco. He has used antacids periodically. He reports no melena or fever, and his weight is stable. He has occasional dry cough, no hoarseness.
On exam, his blood pressure is 145/80 mm Hg, pulse 88/min, respiration in 15/min, he is afebrile. His body mass index is 32, and he is not pale. Chest and cardiac and abdominal exam are unremarkable.
What would you advise as the best next step?
- A. An 8-week trial of proton pump inhibitor (PPI) use once a day before dinner
- B. An upper endoscopy
- C. A barium swallow study
- D. A 24-hour pH test off acid blocking medications
QUESTION 2
A 55-year-old woman presents with chronic reflux symptoms including heartburn, and chest pain for 10 years. She has used several PPIs over the years with variable control in her symptoms. She does try to adhere to an anti-reflux diet and lifestyle. She avoids recumbency for 2–3 h after dinner. She does not smoke or drink alcohol. She reports her symptoms currently occur 3 times a week despite use of PPI twice daily 30 min before breakfast and dinner.
She has undergone an upper endoscopy off PPI which showed LA grade B esophagitis. She does have a 3 cm hiatal hernia. Her weight is stable, and body mass index is 33. She does not report melena, cough, or hoarseness. On exam her vital signs are stable. Chest, cardiac, and abdominal exam are unremarkable.
In addition to advising weight loss, what would you recommend next to manage her reflux symptoms?
- A. Add a histamine 2 receptor antagonist at nighttime
- B. Refer for anti-reflux surgery
- C. Esophageal impedance-pH on PPI
- D. Bravo testing off PPI
QUESTION 3
A 40-year-old man presents with a persistent dry cough and mild hoarseness for a year. He has no shortness of breath, chest pain, regurgitation, dysphagia, or heartburn. He does not smoke tobacco and is otherwise in good health. He is not on any medications. He has been evaluated by a pulmonologist and an ENT specialist. He was told his cough and hoarseness may be due to acid reflux disease as chest x-ray, pulmonary function tests, blood work, allergy tests, and indirect laryngoscopy are normal. The patient's physical exam is unremarkable.
What would you recommend as the best next step in the management of this patient?
- A. An upper endoscopy
- B. A trial of high dose PPIs for 8 weeks
- C. pH testing off PPI
- D. 24 pH testing on PPI
