IMC Evidence Based Medicine Case on Gastroesophageal Reflux Disease
Hart Burns is a 45 year-old man who presents to the IMC with complaints of “heartburn”. Apparently he has suffered with retrosternal burning discomfort on and off for the last 5 years. It is usually worse after large meals and when he lies down for bed. Occasionally he will “burp” a bitter tasting fluid into his mouth. The symptoms started shortly after he “sprained” his knee and stopped exercising, subsequently gaining 30 pounds in weight. He has been self treating at home with Tums and over the counter famotidine as needed, but the symptoms have become more frequent, and sometimes these medications are of limited benefit. He denies any difficulty or pain with swallowing, nausea or vomiting, black or tarry stools, weight loss or fatigue. He denies any other chest pain or shortness of breath. His bowels are regular and he has no other abdominal pain. He denies fever, chills, headache, dizziness, sinus pain, sore throat, dysuria, hematuria, erectile dysfunction, weakness or numbness in arms or legs, skin rash or lesions, or polyuria or polydipsia. He states he was seen at ER three months ago with the retrosternal burning, they gave him an aspirin and did an exercise stress test, which he “passed”. He was told to follow-up at the IMC, and that is why he presents today.
Past Med Hx: Hypertension, Left knee sprain Past Surg Hx: None Allergies: Penicillin (rash) Medications: Enalapril 20 mg daily (gets at health department) Family Hx: Mother and Father alive, both with hypertension; no family hx of cancer, IBD, or celiac disease Social Hx: Former tobacco user, 1 ppd for 10 years, quit 10 years ago; occasionally drinks 1 to 2 beers on weekend when watching games; denies illicit; lives with wife in home, monogamous heterosexual; works as a landscaper / snow removal laborer, has no health insurance Vitals: Temp 98.4 BP 126/84 Pulse 80 Resp 14 Ht 72 inch Wt 235# BMI 31.9 HEENT: PERRLA, EOMI, TM’s pearly gray bilateral, turbinates pink and moist, oral mucosa moist, good dentition, posterior pharynx within normal limits Neck: Supple, no JVD, no lymphadenopathy Heart: RRR, no murmurs, gallops, or rubs Lungs: BCTA, no wheeze, rhonchi or rales Abdomen: Soft, + BS, NT/ND, no mass, hernia or organomegaly; absent Murphy’s sign; no flank tenderness to palpation Rectal: normal sphincter tone; no masses; smooth prostate, hemoccult negative Neuro: Grossly intact Skin: No lesions or rashes Plato Review: ER visit 3 months ago, revealed normal CBC, CMP, troponin. Exercise stress test to 15 metabolic units, no EKG changes at 90% predicted maximal heart rate. Read as “normal stress test”. Please utilize the ACP GERD 2012 best practice advice article to answer the following questions:
• What is the most likely diagnosis for our patient? • How many US adults report some symptoms of reflux disease? What percent report
symptoms on a weekly or more frequent basis?
• What is the definition of gastroesophageal reflux disease? Is tissue injury necessary to
• What percent of patients with GERD have nonerosive disease? What percent of
patients with chronic heartburn symptoms have Barrett’s esophagus? What is Barrett’s’s esophagus?
• Are GERD and Barrett esophagus associated with an increased risk for esophageal
• What is the absolute risk for adenocarcinoma of the esophagus in the general
• Has it been increasing, decreasing or staying the same over the past 40 years? • What is the cancer risk of Barrett esophagus with no dysplasia? With high grade
Mr. Burns requests a referral to gastroenterology for an upper endoscopy. Answer the following questions to see if you want to send him to GI now.
• True or False. GERD symptoms have a poor sensitivity and specificity as predictors of
• What percent of patients who develop adenocarcinoma of the esophagus have no
heartburn? What is the yearly risk of esophageal adenocarcinoma among patients 50 years or older with heartburn?
• Is esophageal adenocarcinoma more common in men or women? • True or False. The risk for esophageal adenocarcinoma in women with GERD is
roughly equal to that of breast cancer in men.
• What percent of patients with nondysplastic Barrett esophagus followed for more than 5
• True or False. Direct evidence shows screening and surveillance endoscopy programs
actually decrease death from adenocarcinoma of the esophagus.
In most patients presenting with typical GERD symptoms,
• what treatment is warranted? • Is endoscopy indicated in these patients?
You let Mr. Burns know that a referral to gastroenterology and endoscopy is not necessary at this time. You have him see Tom Balchak (IMC social worker) and find out he is eligible for the Protonix (pantoprazole) patient assistance program, he fills out the paperwork, and you start him on pantoprazole 40 mg daily. He returns for follow up 4 weeks later, and states the heartburn symptoms are still not gone. Please answer the following questions to help Mr. Burns.
• If once daily PPI therapy is unsuccessful in a patient with typical GERD symptoms, what
• True or False. Any PPI (dexlansoprazole, esomeprazole, lansoprazole, omeprazole,
pantoprazole, or rabeprazole) may be used because absolute differences in efficacy for symptom control and tissue healing are small.
• For most PPIs, what timing of dosing may provide optimal efficacy?
You increase Mr. Burns’ pantoprazole to 40 mg twice daily (and notify Dave Conrad RN so his drug program can be updated). He returns 8 weeks later and states he is continuing to have breakthrough burning pain retrosternally.
• Is GI referral and further investigation with an upper endoscopy now warranted? • In patients with GERD, which alarm features merit investigation with upper endoscopy
because of its yield of potentially clinically actionable findings, such as finding cancer of the esophagus or stomach, bleeding lesions in the foregut, or stenosis of the esophagus or pylorus?
• Which of the following groups of patients with GERD (and no alarm features or failure of
PPI BID therapy) require routine screening upper endoscopy?
o Women o Patients younger than 50 o Men older than 50 with symptoms more than 5 years and nocturnal symptoms,
hiatal hernia, elevated BMI, tobacco use, and intra-abdominal distribution of fat
Mr. Burns is seen by Dr Verbeck and has an upper endoscopy which reveals severe erosive esophagitis. Upon further query by Dr Verbeck, the patient admits he has not been using the pantoprazole because he read on the internet that use could be associated with osteopenia, and his grandfather died at age 96 after breaking his hip. Dr Verbeck counsels the patient based on the benefit-risk profile in his current situation and the patient agrees to take the pantoprazole 40 mg twice daily.
• Should Mr. Burns have a follow-up upper endoscopy scheduled? If so, when and why?
Mr. Burns is compliant with the pantoprazole, and feels much better. Eight weeks later Dr Verbeck repeats the upper endoscopy. The endoscopy shows the esophagitis has healed, but Dr Verbeck see’s a short segment of tissue consistent with Barrett’s esophagus in the distal esophagus and takes several biopsies. Pathology findings are consistent with Barrett’s esophagus with no dysplasia.
• When should his next upper endoscopy be scheduled? • In patients with chronic GERD (symptoms > 5 years), if no Barrett’s is found on an initial
endoscopy (normal endoscopy), are further endoscopic screenings necessary?
• What are the risks of upper endoscopy? What are the costs?
Bonus Question (the answers for this is not in the attached guideline)
• What are lifestyle recommendations that should be made to patient’s with GERD?
Case author Rex Wilford. Version history 12-18-2012
C E R T I F I C A T E 2012/2013 Biola Organic Cosmetics Ltd. Szivárvány u. 8 6000 Kecskemét Based on annual inspections against the International Demeter Standards we herewith confirm certification for the above mentioned enterprise for the following products: Processed Products: baby cleansers (Chamomile baby bath) baby oil (Herbal baby care oil) bath additives (Pepperm
Planned Indicators CAT® Engine Repair Indicators (Continued) CAT Final Drive Repair Indicators CAT Transmission Repair Indicators Planned Indicators Description Problem Indicators Possible Causes Problem Indicators Possible Causes Problem Indicators Possible Causes S•O•S Services S•O•S Services provide the best insight White smoke