Question of the Week # 371

371)  A 45 year caucasian man is evaluated in your office prior to surgery for refractory heartburn symptoms. He was diagnosed with Gastro-esophageal reflux disease 2 years ago. Initially, his disease was mild and was responsive to over the counter antacids. He was started on PPI ( proton pump inhibitor trial 6 months ago and has not responded. He switched physicians and tried different brands of proton pump inhibitors with no benefit. An endoscopy was performed a year ago and repeat endoscopy 3 months ago revealed erosions and inflammations consistent with reflux esophagitis with out any background of barrett’s esophagus. The patient is scheduled for fundoplication surgery and is here for pre-operative evaluation. Which of the following should be performed at this time ?

A) 24 hour esophageal pH monitoring

B) Barium esophagogram

C) Esophageal motility studies

D) No additional tests needed , clear patient  for surgery

E) H.Pylori Urea Breath Test

20 Responses

  1. e,

  2. A

  3. E) H.Pylori Urea Breath Test

  4. A) 24 hour esophageal pH monitoring

    • What are the indications to do 24 hour pH monitoring?

      • Persistent Symtoms on PPI and is done before anti-reflux surgery??

      • I am confused on this now…while he needs 24 hr pH monitoring before surgery do we need to do H.Pylori Urea Breath Test before that since he has erosions with out any background of barrett’s esophagus?? Not consistent with GERD

      • Barrett’s is a long term complication of GERD. Presence of Barrett’s is not needed to diagnose GERD. GERD is a clinical diagnosis and an endoscopic findings of distal esophagitis. reflux pattern , erosions indicate Reflux esophagitis consistent with GERD. Does he still need 24 hour pH monitoring?
        H.Pylori is not associated with GERD – it is associated with Peptic ulcer, gastric cancer and dyspepsia. Testing for H.Pylori is never recommended in GERD.

      • The diagnosis is obvious but i thought u needed to confirm that the erosions were indeed from GERD before surgery so is it

        D) No additional tests needed , clear patient for surgery ?

      • 🙂
        Ok, what are all the indications for esophageal manometry that you know of ?
        Always use elimination method through quick elimination of choices

      • hmm Achalasia, diffuse esophageal spasm…

      • Scleroderma!!! rule it out, but woud’nt he have other symptoms of Scleroderma ? but i got the concept! Great Q! Thank you!

        C) Esophageal motility studies

      • Answer is C. Preoperative esophageal motility studies are often performed prior to anti-reflux surgery because occassionally it may disclose an alternative diagnosis like scleroderma or achalasia ( in such cases, anti-reflux surgery is contraindictaed. Though these diagnoses are less likely given the clinical picture, they may occur rarely and even such rare possibility should be ruled out before patient goes for such major surgery) Moreover, it can guide the surgeon in modification of approach – however, recent studies have shown that such modification is not necessary. American Gastroenterological Association and most experts still agree that esophageal manometry is a desirable investigation prior to Surgery for above reasons.

        3) Next obective of this question is to understand the indications of 24 hour pH monitoring : This is indicated only in patients with high clinical suspicion of GERD that is unresponsive to PPI trial and if the EGD is negative . So, please remember that EGD must be done first in refractory cases and if EGD is negative then only proceed with 24 hr pH monitoring. The criteria for anti-reflux surgery is clear failure of PPIs in GERD and establishing the diagnosis of GERD prior to corrective surgery. In the above question, diagnosis is clearly confirmed by endoscopic appearance and does not need additional 24 hour pH monitoring to confirm it

      • Can you please explain it though?

  5. e

  6. Ph monitoring so it’s A

  7. c, to rule out any achalasia which is contraindicated in fundoplication

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