A 40-year-old woman presents to her primary care physician with ongoing reflux symptoms despite taking acid blockers. She describes a burning sensation in her chest, even after small meals. She avoids eating fatty and spicy foods that aggravate her reflux. She had previously used oral antacids but discontinued them due to intolerable constipation. For the last 2 months, she has taken daily omeprazole in the morning and ranitidine at bedtime without relief of her symptoms. She has also stopped drinking alcohol but is not interested in quitting smoking. She states she has been unable to lose excess weight, and her medical history is significant for obesity. Vital signs include temperature 36.7°C (98°F), blood pressure 120/67 mm Hg, heart rate 90/min, and respiratory rate 14/min. Her body mass index (BMI) is 33 kg/m2. Her physical examination is otherwise unremarkable. What is the most appropriate next step in management?
Correct answer: Upper GI endoscopy
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The diagnosis of gastroesophageal reflux disease (GERD) is based on clinical findings. Empiric treatment with lifestyle modification and acid-reducing medications are indicated. An upper GI endoscopy is indicated in patients whose symptoms do not improve after 8 weeks of therapy with a proton-pump inhibitor (PPI), such as this patient. Endoscopy is also recommended for individuals with “alarm symptoms” of dysphagia, involuntary weight loss, anemia, GI bleeding, or new onset dyspepsia after age 60.
Screening for Barrett esophagus with an upper endoscopy is indicated in adults with risk factors (age over 50, male sex, obesity, tobacco use, first-degree relative with Barrett esophagus or adenocarcinoma).
The initial management of GERD includes recommendations for lifestyle and dietary modification in all patients. These include the following:
- Smoking cessation
- Avoid tight-waisted clothing, which can increase intraabdominal pressure and reflux symptoms
- Avoid foods that make reflux worse, such as chocolate, carbonated beverages, onions, and peppermint
- Weight loss if overweight or obese
The most appropriate next step in the management of this patient with ongoing reflux symptoms despite acid blockers is an upper GI endoscopy. The patient’s symptoms have not improved with the use of omeprazole and ranitidine for 2 months, which suggests the need for further evaluation.
An upper GI endoscopy is recommended in patients with GERD when they do not respond to initial treatment with proton-pump inhibitors (PPIs) or when they have “alarm symptoms” such as dysphagia, involuntary weight loss, anemia, GI bleeding, or new onset dyspepsia after age 60. In this case, the patient’s ongoing symptoms despite medication use warrant an endoscopy to assess the extent of esophageal damage and rule out potential complications.
Additionally, screening for Barrett esophagus with an upper endoscopy is indicated in adults with specific risk factors, which include obesity, tobacco use, and a family history of Barrett esophagus or adenocarcinoma. Given that this patient is obese and continues to smoke, she is at increased risk for Barrett esophagus, making an endoscopy even more appropriate.
While lifestyle modifications, including smoking cessation, weight loss, and dietary changes, are important in the long-term management of GERD, the current clinical scenario calls for an endoscopy to evaluate the extent of the disease and potential complications.