A 35-year-old woman is evaluated for nocturnal heartburn and regurgitation. She has a 5-year history of gastroesophageal reflux disease. She takes omeprazole every day 30 minutes before breakfast. She works as a musician and has concerts on weekends. After her concerts, she eats heavy meals at a late hour and experiences nocturnal symptoms that interfere with sleep. During the week, she has minimal symptoms when she maintains her normal routine. She has no other concerning symptoms. She does not smoke cigarettes.
On physical examination, BMI is 25.
Which of the following is the most appropriate additional management?
A. Increase omeprazole to twice daily
B. Laparoscopic fundoplication
C. Lifestyle modifications
D. Upper endoscopy
E. Wireless pH testing
MKSAP Answer and Critique
The correct answer is C. Lifestyle modifications. This content is available to MKSAP 19 subscribers as Question 81 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate additional management in this patient with nocturnal gastroesophageal reflux disease (GERD) is to recommend lifestyle modifications (Option C). Weight loss and tobacco smoking cessation should be recommended to patients with GERD who are obese and smoke, respectively. Patients with nocturnal GERD should avoid late-evening meals by eating at least 3 hours before bedtime and should elevate the head of the bed. Avoidance of large meals and fatty foods that stay in the stomach for longer periods is also helpful if adherence can be maintained. Drastic changes in the diet are not generally recommended because they are difficult to maintain. However, if a trigger is identified, such as alcohol, it is reasonable to recommend elimination of that trigger from the diet.
Although some patients require dosage escalation to twice-daily proton pump inhibitor (PPI) therapy (Option A), directed lifestyle modifications should first be attempted for the patient's weekend symptoms, which are related to large late-night meals. Her symptoms are otherwise controlled with the existing drug regimen. Dosage escalation may be appropriate if a trial of lifestyle modifications is not successful.
Surgical treatments for GERD include laparoscopic fundoplication (Option B). However, surgery is infrequently required; indications include failure of optimal PPI therapy with documented evidence of ongoing acid reflux, desire to stop medication, and intolerable medication side effects. These indications do not apply to this patient.
Most patients with GERD have normal findings on upper endoscopy (Option D). Upper endoscopy is warranted in patients reporting dysphagia, weight loss, hematemesis, or failure to respond to treatment. Lifestyle modifications should be introduced before upper endoscopy.
Wireless esophageal pH testing (Option E) can quantify acid exposure in the esophagus, confirm adequacy of acid suppression therapy, and differentiate between acid and nonacid reflux. Because the patient has classic symptoms of GERD that are generally well controlled with a PPI and weekend symptoms that should be amenable to lifestyle modifications, wireless pH testing is unnecessary.
- Weight loss and tobacco smoking cessation should be recommended to patients with gastroesophageal reflux disease who are obese and smoke, respectively.
- Patients with nocturnal gastroesophageal reflux disease should avoid late-evening meals by eating at least 3 hours before bedtime and should elevate the head of the bed.