MKSAP: 50-year-old man is evaluated for persistent heartburn

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 50-year-old man is evaluated for persistent heartburn and regurgitation despite taking a high-dose proton-pump inhibitor twice a day for 6 months. His symptoms have improved, but he continues to have symptoms many times a week. He has not had dysphagia, chest pain or weight loss. He has significantly modified his diet. His only medication is esomeprazole, 40 mg twice a day, which he takes as directed.

Physical examination is notable for a BMI of 34. The remainder of the physical examination is normal.

Endoscopy reveals persistent esophagitis and a moderately large hiatal hernia.

Which of the following is the most appropriate next step in treatment?

A: Add twice-daily sucralfate
B: Fundoplication
C: Increase dose of esomeprazole
D: Radiofrequency ablation

MKSAP Answer and Critique

The correct answer is B: Fundoplication. This item is available to MKSAP 16 subscribers as item 52 in the Gastroenterology and Hepatology section.

This patient should be offered fundoplication. He continues to have persistent gastroesophageal reflux disease (GERD) manifested by esophagitis despite high-dose proton-pump inhibitor (PPI) therapy. Patients with persistent symptoms despite PPI therapy should be assessed for adherence to medication regimens and correct administration (30 to 45 minutes before a meal). Patients should also be assessed for other symptoms that may indicate alternative diagnoses such as eosinophilic esophagitis, heart disease, or achalasia. The next step in evaluation should be endoscopy; if endoscopy is unrevealing, 24-hour ambulatory pH testing should be performed. In this patient, esophagitis on endoscopy indicates persistent uncontrolled GERD despite maximal medical therapy. The notable endoscopic findings make it unnecessary to perform an ambulatory reflux study. The best treatment is surgical fundoplication, which has been shown to be effective in controlling excessive distal esophageal acid exposure. The best outcomes are observed in patients whose symptoms respond to medical therapy and who have few comorbidities. Relief of symptoms with surgery is significant but not always long-lasting; more than half of patients who have surgery for GERD resume regular PPI therapy 10 to 15 years after surgery. Side effects of surgery, which include dysphagia, gas-bloat syndrome, and diarrhea, occur in approximately 25% of patients.

Increasing the dose of esomeprazole or adding sucralfate would not lead to long-term healing of esophagitis and symptom relief in this 50-year-old patient, given that doses of greater than 80 mg of esomeprazole per day do not lead to appreciably increasing acid suppression. Sucralfate is prescribed for short-term use as an adjunct to PPI therapy.

Endoscopic antireflux procedures such as radiofrequency ablation have not been shown to achieve significant long-term reduction in esophageal acid exposure and remain experimental at this time.

Key Point

  • Fundoplication is a therapeutic option for confirmed gastroesophageal reflux disease that is refractory to proton-pump inhibitor therapy.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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