Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Question 4 Andy W., a 31 y.o old computer graphic designer, presents to his primary care physician for annual visit. He reports a chronic cough present for >2months but no heartburn. Chest x-ray and physical exam are unrevealing. Which of the following symptoms is NOT suggestive of Gastroesophageal Reflux Disease? A.Hoarseness B.Dental Erosions C.Steatorrhea D.Chest pain E.Odynophagia

Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Question 4 C. Steatorrhea is not classically associated with GERD. The other symptoms mentioned are atypical manifestations of the disease. Heartburn and regurgitation are the most common complaints. In patients with atypical symptoms, endoscopic findings of esophagitis are less common and ambulatory 24-hour pH monitoring and/or trial of PPI therapy may be required to confirm the diagnosis.

Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Question 5 Of the following four patients, who is most likely to benefit from screening for Barrett’s Esophagus? A.35 y.o white male with GERD for 1 year asymptomatic on PPI therapy B.55 y.o white female with GERD x 5 years asymptomatic on PPI therapy C.55 y.o black male with reflux symptoms x 6 months not yet on PPI therapy D.60 y.o white male with GERD x 10 years asymptomatic on PPI therapy

Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Question 5 D. Screening for Barrett’s esophagus is controversial. There is no evidence of mortality benefit with regular screening. However, because Barrett’s is a pre-malignant state, identifying patients with Barrett’s may benefit that patient. Risk factors include white race, male gender and duration of GERD symptoms.

Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Question 6 Nadia, a 30 y.o black female, has a 6 month history of heartburn that has not improved after 2 months of maximal PPI therapy and lifestyle modification. She denies any dysphagia, weight loss or anorexia. Which would be the next appropriate step in her management? A.Barium Swallow B.Surgical Fundoplication C.Upper Endoscopy with biopsy D.Addition of H2 blocker E.Ambulatory 24-hour Esophageal pH monitoring

Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Question 6 E. Ambulatory esophageal pH monitoring. In patients who do not respond to PPI therapy, pH monitoring while on therapy will help confirm the diagnosis of GERD. Combination therapy with PPI and H2 blocker has not been shown to be better at controlling symptoms than single-agent therapy, though there is evidence that addition of an H2 blocker to maximal PPI therapy may help decrease nocturnal acid secretion (Xue S et al. Aliment Pharmacol Ther Sep;15(9):1351-6)