GI Distress in a Middle-Aged Woman

For several months, a 52-year-old woman has had burning discomfort in the region of her lower sternum and frequent acid/sour sensations in her throat; the symptoms are usually associated with burping after meals and recumbency. Antacids provide sporadic and transient relief. Her appetite remains good, and she has not lost weight. She denies changes in bowel habit, hematemesis, hematochezia, pulmonary symptoms, dysphagia, and odynophagia. Although her symptoms are bothersome, they have not caused her to miss work.

HISTORY

The patient is otherwise healthy. She has mild hypertension, which is well controlled with a low-dose angiotensin-converting enzyme inhibitor. She has no history of similar GI symptoms.

PHYSICAL EXAMINATION

This slightly overweight woman has normal vital signs. Examination of the mouth reveals no abnormalities, and no abnormal lymph nodes are palpable. Chest is clear and heart is normal. Bowel sounds are normal, and no organomegaly or abdominal masses are noted. There is minimal or no tenderness in all 4 quadrants with direct, deep palpation. Other physical findings are normal. No occult blood is detected in her stools.

LABORATORY AND IMAGING STUDIES

Results of a chemistry panel, biochemistry panel, and cholesterol measurements are normal. Hemoglobin level is 12.9 g/dL; mean corpuscular volume, 85 fL; and serum ferritin level, 65 ng/mL. Chest radiograph is normal, with no gross evidence of a hiatal hernia.

Which of the following statements about this patient's managementand prognosis is not true?

• Empiric therapy with proton pump inhibitors (PPIs) without further diagnostic testing is a reasonable initial strategy.

• Medical therapy for reflux will probably not need to be continued indefinitely.

• If medical therapy fails, anti-reflux surgery will most likely produce an excellent outcome.

• If medical therapy is effective, anti-reflux surgery is a reasonable future option for long-term maintenance.

CORRECT ANSWER: C

This patient has the classic clinical features of gastroesophageal reflux disease (GERD): heartburn, substernal burning and regurgitation, postprandial symptoms, and relief with antacids.

Diagnosis of GERD. Although not universally accepted by the endoscopy community, a growing trend is to diagnose and treat empirically with a PPI when symptoms are classic. Endoscopy is reserved for the following:

• Symptoms suggestive of complications (eg, dysphagia, odynophagia, anemia, weight loss).

• Poor response to or recurrence of symptoms with PPI therapy.

• Situations in which investigation is needed before surgery.

In patients who are younger than 55 years, have classic symptoms, and respond to empiric PPI therapy, the presumptive diagnosis of GERD has a sensitivity of about 75% and a specificity of about 60%.^1-3 Thus, choice A is a reasonable initial approach in this patient.

PPI therapy. In most patients with GERD, whether the disease was diagnosed empirically or endoscopically, a course of PPIs is the initial therapy of choice. Antacids and H₂ blockers relieve GERD symptoms acutely in many patients; however, PPIs seem more effective, especially at reducing complications of GERD (such as peptic strictures that require dilation) and at healing erosive gastritis.¹

In many patients, PPI therapy may not need to be continued indefinitely. In 1 recent study, a PPI was given for 12 weeks, then replaced by a less aggressive therapy or a lower dosage of the PPI. At 1 year, 50% of the patients were doing well without PPIs, although other, less aggressive therapies were often required (eg, prokinetics, H₂ blockers). Age younger than 40 years and severe heartburn symptoms predicted an inability to be successfully weaned from PPIs.³

This woman is 52 and has moderate symptoms. Thus, choice B is true: she probably can be weaned from PPI therapy.

Anti-reflux surgery. Indications for surgery include:

• Atypical symptoms of GERD that are relieved by PPI therapy.

• Large-volume regurgitation and aspiration symptoms not controlled by PPIs.

• Long-term medical therapy not feasible because of concerns about medication costs, compliance, or other issues.

In many trials, which evaluated a variety of surgical techniques, the best predictors of an optimal surgical outcome were a good response to medication and classic--rather than atypical--symptoms.⁴ Thus, choice D is true.

In a large VA study with a 10-year follow-up, 62% of patients with GERD who underwent surgery were using anti-reflux medications (32% were using PPIs); 16% required further anti-reflux surgery. The incidence of esophageal cancers in those who underwent surgery and in those who did not was similar (2.7% in the surgery group vs 4.0% in those who received only medical therapy), and the total all-cause mortality at 10 years was actually higher in the surgery group (40% vs 28%).⁵

Thus, the likely outcome of anti-reflux surgery can hardly be characterized as "excellent" in most patients--and especially not in a patient whose response to PPI therapy is suboptimal. Consequently, choice C is not true, making it the correct answer.

Newer endoscopic and endoluminal techniques are being evaluated. Early results are encouraging, especially with regard to lack of adverse effects (eg, perforation, bleeding). However, more experience and longer-term follow-up are needed to determine the true efficacy and durability of the results of these new approaches.

Outcome of this case. A 7-day trial of empiric therapy with omeprazole, 40 mg/20 mg, was started. The patient's symptoms promptly resolved. Omeprazole was continued for 12 weeks, at which time an H₂ antagonist was substituted. She remains asymptomatic after 1 year.

References:

REFERENCES:

1.

Fisher RS, Parkman HP. Management of nonulcer dyspepsia.

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DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology.

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3.

Talley NJ, Vakil N; Practice Parameters Committee of the American College of Gastroenterology. Guidelines for the management of dyspepsia.

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Hinder RA, Libbey JS, Gorecki P, Bammer T. Antireflux surgery. Indications, preoperative evaluation, and outcome.

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Spechler S, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial.

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