MKSAP Quiz: 2-month history of a burning sensation
A 45-year-old man is evaluated for a 2-month history of a burning sensation starting in his stomach and radiating into his chest, usually occurring 4 to 5 times weekly. He says that he usually eats dinner late and then goes to sleep. He often wakes up with a sour taste in his mouth. Following a physical exam, which is the most appropriate next step in management?
A 45-year-old man is evaluated for a 2-month history of a burning sensation starting in his stomach and radiating into his chest, usually occurring 4 to 5 times weekly. He says that he usually eats dinner late and then goes to sleep. He often wakes up with a sour taste in his mouth. He reports no dysphagia or unintentional weight loss. He takes no medication.
On physical examination, vital signs are normal; BMI is 34. The remainder of the examination, including abdominal examination, is unremarkable.
Which of the following is the most appropriate next step in management?
A. Ambulatory pH testing
B. Barium esophagography
C. Empiric trial of a proton pump inhibitor
D. Upper endoscopy
MKSAP Answer and Critique
The correct answer is C. Empiric trial of a proton pump inhibitor. This content is available to MKSAP 18 subscribers as Question 44 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate next step in the management of this patient is the initiation of a proton pump inhibitor (PPI) in conjunction with lifestyle and dietary changes. The diagnosis of gastroesophageal reflux disease (GERD) is made clinically. This patient's symptoms of burning pain in his abdomen and chest and a sour taste in his mouth occurring more than a few times a week are consistent with GERD. Due to the frequency of his symptoms, the best initial treatment is a once-daily PPI for a period of up to 8 weeks. Weight reduction is suggested for patients with recent weight gain or overweight. Interventions such as raising the head of the bed and eliminating meals within 2 to 3 hours of bedtime are helpful for nocturnal GERD. Cessation of alcohol and tobacco use is universally supported. Treatment for less frequent symptoms could include famotidine or other H2 blockers.
Ambulatory pH testing is used to determine acid exposure in the esophagus in patients considering antireflux surgery. Indications for surgery include patient preference to stop taking medication, medication side effects, and refractory symptoms despite optimized medical therapy. Laparoscopic fundoplication and bariatric surgery (in patients with obesity) are surgical methods used to treat GERD. This patient has no surgical indications.
A barium esophagram is the initial test for evaluation of achalasia. The main symptom of achalasia is dysphagia to both solids and liquids along with regurgitation of undigested food and saliva. Patients may also report unintentional weight loss, chest pain, and heartburn. A barium esophagram is not indicated because this patient's symptoms are more consistent with GERD than with achalasia.
Upper endoscopy is indicated in patients with alarm symptoms, such as dysphagia or weight loss, and in patients whose symptoms do not respond to a PPI. Upper endoscopy is not indicated in this patient with typical GERD symptoms because most patients with typical symptoms have normal upper-endoscopy findings. Upper endoscopy is useful for the evaluation of the esophagus to identify damage in the form of erosive esophagitis, stricture, or Barrett esophagus.
Key Point
- Patients with a clinical diagnosis of gastroesophageal reflux disease should start an empiric trial of a proton pump inhibitor in conjunction with lifestyle and dietary changes, with no further testing.