Question of the Week # 447

447) A 54 year old caucasian man is seen in your office for initial visit examination. He recently moved from Texas to your town and would like to establish care with you. He has no significant past medical problems except for Gastro-Esophageal Reflux Disease for twenty years. He previously suffered hearburn symptoms that were controlled with over the counter ranitidine . Later, his symptoms became refractory and he was started on omeprazole by his previous physician. He currently takes 20 mg of Omeprazole and is very happy that he has been asymptomatic for the past 1 year.  He has had colonoscopy 2 years ago and this was normal. His father died of Colon cancer at the age of 70. He does not smoke.

Which of the following is the most appropriate action at this time ?

A) Instruct him to continue Omeprazole and follow up in 1 year.

B) Refer to gastroenterology for Upper Endoscopy

C) 24 hour Esophageal pH monitoring

D) Stool Guaic test and Flexible Sigmoidoscopy

E) Stool test for H.Pylori antigen

23 Responses

  1. d

    • But Shweta, he had a colonoscopy 2 years ago and that was normal. Why d?

  2. the answer is A

  3. B. The patient is above 45 and needs upper GI endoscopy although his GERD symptoms are under control with PPI.

  4. I thought it should be 10 yrs before we do biopsy for barrett, here there is no mention of time

  5. I agree with B. Patient has a history of long standing GERD thus needs endoscopy to rule out Barrett’s esophagus.

    • I agree with dr Einstein. His answer is much more reasonable than mine. We need to do endoscopy every 5 years for patients with GERD to rule out Barrett’s esophagus.

  6. I think I will go with E. I will r/o h pylori and then if it is just due to reflux esophagitis ask him to continue omeprazole. His father died at 70, so that doesn’t make me think of more often screening for this individual. Let me know if we are missing anything here.

  7. well I think I missed his long standing GERD, anyway we may scope him for any major changes.

  8. This patient has two issues to be resolved upon: For the COLON nothing to be one at this time. For the GERD, I would say that given that his hx is so long ( +/- 20years) he probably should have a BASELINE EGD to evaluate this GERD sine he is a new patint. I would say letter B.

    • Correct . Patients with chronic GERD greater than 5 years needs to have a baseline EGD to screen for barret’s esophagus. Once Barrett’s is found , EGD intervals is based on whether or not dysplasia is present

  9. A

  10. h pylori?

  11. b, longstanding gerd

  12. `B.

    Pt has long standing GERD need to get BLN endoscopy.

  13. B

  14. B…..due to age and symptoms

  15. NEVER REFER in 1 answer questions

  16. Reflux has nothing to do with H pylori

  17. He did have heartburn……Possible Pylori

  18. the answer is B for long term gerd u should rule out barrett’s esophagus needs to be ruled out.

  19. H. Pylori is detected by endoscopy and CLO test for H.Pylori, there is also the stool antigen assay for H. Pylori, high sensitivity and obviously less invasive, don’t think it is appropriate to discharge the patient, due to history of refractive disease, therefore need to exclude H.Pylori, and possible eradication therapy. PPi just control the symptoms and not the cause!! not sure whether to choose stool antigen assay or endoscopy?

  20. thanks for the great answer from archers, in common primary care practice patients with GERD and treatment, will have EGD earlier than 5 years to have additional CLO test for H.pylori and biopsies to determine diagnosis of eosophagitis/gastritis/ ulcers!! but screening for barretts by egd is correctly done after 5 years for greatest sensitivity of results.

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