MKSAP Quiz: Evaluation for gastroesophageal reflux disease

MKSAP Answer and Critique

The correct answer is D. Upper endoscopy. This content is available to MKSAP 19 subscribers as Question 17 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.

The most appropriate management is upper endoscopy (Option D). This patient has longstanding (≥5 years) gastroesophageal reflux disease (GERD) along with multiple risk factors for esophageal cancer, including male sex, age older than 50 years, hiatal hernia, obesity with intraabdominal distribution of fat, and tobacco use. Endoscopy to assess for Barrett esophagus is indicated. The diagnosis of Barrett esophagus is confirmed by the finding of salmon-colored mucosa on endoscopy with columnar epithelium with acid-mucin–containing goblet cells on histopathology. Barrett esophagus progresses as follows: intestinal metaplasia, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia, intramucosal carcinoma, and, finally, invasive adenocarcinoma. Patients with high-grade dysplasia and confirmed low-grade dysplasia should undergo treatment to eradicate all neoplastic and at-risk epithelium. Patients with Barrett esophagus without dysplasia should undergo surveillance endoscopy every 3 to 5 years to monitor for dysplasia or precancerous changes.

Bariatric surgery (Option A) might be a reasonable option to treat this patient's obesity. However, before that decision is made, screening this higher-risk patient for esophageal cancer should be performed and cancer should be treated, if found.

In the setting of GERD, an esophageal motility study (Option B), such as esophageal manometry, would be indicated to rule out a motility disorder before antireflux surgery. This patient reports good symptom control with medical therapy, however, and does not require antireflux surgery. Furthermore, he has no other symptoms, such as dysphagia, that suggest a motility disorder. Therefore, a motility study is not indicated.

Surgery is not required because this patient's GERD is currently well controlled with medical therapy. Surgery is infrequently required for GERD; indications include failure of optimal proton pump inhibitor therapy, desire to stop medication, and intolerable medication side effects. Surgical treatments for GERD are laparoscopic fundoplication (Option C) or bariatric surgery for obesity, as well as magnetic sphincter augmentation (a magnetic ring is placed around the lower esophageal sphincter without surgical alteration of the stomach). Surgery is most effective in patients with typical symptoms of heartburn and regurgitation that respond to therapy. However, about one third of patients require resumption of a proton pump inhibitor 5 to 10 years after surgery. Postoperative complications include dysphagia, diarrhea, and inability to belch because of a tight fundoplication.

Key Point

• Individuals with gastroesophageal reflux disease symptoms for 5 years or more and three or more risk factors (male sex, age >50 years, White race, obesity, tobacco use, and family history of Barrett esophagus or esophageal adenocarcinoma in a first-degree relative) should be screened for Barrett esophagus.