MKSAP: 48-year-old man with a 4-week history of heartburn


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

A 48-year-old man is evaluated for a 4-week history of heartburn that awakens him at night. The symptoms occur about three times per week. He has been taking over-the-counter antacids with incomplete relief. Food triggers include coffee and spicy foods. He has not had unintentional weight loss or difficulty swallowing.

Physical examination and laboratory studies are normal.

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

A. Ambulatory esophageal pH monitoring
B. Esophageal manometry
C. Trial of a proton pump inhibitor
D. Upper endoscopy

MKSAP Answer and Critique

The correct answer is C. Trial of a proton pump inhibitor.

The most appropriate next step in management is a trial of a proton pump inhibitor (PPI). This patient has classic symptoms of gastroesophageal reflux disease (GERD) in the form of heartburn. Symptoms of heartburn and regurgitation are strong predictors for the clinical diagnosis of GERD. The most appropriate next step in a patient without alarm symptoms (dysphagia, unintentional weight loss, hematemesis, or melena) is an empiric trial of a PPI.

Although ambulatory esophageal pH monitoring is the most accurate technique to diagnose GERD, it is expensive and invasive and is therefore only indicated in patients whose symptoms have not responded to medication. This patient has never taken a PPI previously to control his symptoms, so pH testing is not needed at this point in management.

Esophageal manometry measures the pressure levels in the esophagus and is useful in evaluating esophageal motility disorders such as achalasia. However, this patient has not had dysphagia to solids and liquids, which makes an esophageal motility disorder unlikely.

This patient has not had any alarm symptoms such as difficulty swallowing or weight loss that would warrant an upper endoscopy at this time. An upper endoscopy would be necessary if this patient had alarm symptoms or if his symptoms did not respond to the empiric trial of a PPI.

Key Point

  • In a patient without alarm features (dysphagia, unintentional weight loss, hematemesis, or melena), symptom relief with an empiric trial of a proton pump inhibitor confirms the diagnosis of gastroesophageal reflux disease.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 17 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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