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Case # 2

Case # 2. Mr. Rendly. Mr. Rendly. 39 y/o w/m here for initial evaluation CC: “heartburn symptoms after each meal” This started a year ago, mostly in response to spice foods. It has progressed in frequency and severity.

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Case # 2

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  1. Case # 2 Mr. Rendly

  2. Mr. Rendly • 39 y/o w/m here for initial evaluation • CC: “heartburn symptoms after each meal” This started a year ago, mostly in response to spice foods. It has progressed in frequency and severity. • He sometimes wakes at night with regurgitation if he has eaten shortly before going to bed. He now sleeps on extra pillows. • He denies nausea, early satiety, bloating, cough, asthma, sore throat, chest pain, and voice changes.

  3. Mr. Rendly PMH: Appendectomy at age 7 Medications: He took antacids briefly, but stopped because he didn’t like the taste. Allergies: None

  4. Mr. Rendly Social History: Runs his own lawn and yard maintenance company Family History: Mother 65 y/o with osteoarthritis Father deceased at age 59 with esophageal carcinoma Two siblings and three children, all healthy ROS: Negative

  5. Mr. Rendly’s PE HT:6’2” WT: 200 lb. BP:140/82 P: 68 R:14 T: 98.4º Well developed, well nourished HEENT:Normal oropharynx and mouth Neck:Normal Lungs:Clear to auscultation CV:S1 and S2 normal. No gallop or murmur

  6. Mr. Rendly’s PE (continued) Abdomen:Nondistended, normal bowel sounds, no organomemgaly or masses. No tenderness Rectal:Normal with guaiac negative stool

  7. Do you believe Mr. Rendly has GERD? Does he need a diagnostic study? Stop Here and Discuss

  8. The Gastroenterology Panel Believes: • This presentation is typical for GERD • No diagnostic study is needed

  9. What Is Your Differential Diagnosis? Stop Here and Discuss

  10. Differential Diagnosis Developed by the Gastroenterologists: • Most Likely: • GERD with esophageal stenosis • GERD with erosive esophagitis • Less Likely: • GERD with Barrett’s Esophagus Least Likely: • Esophageal motility disorder • Esophageal carcinoma • Esophageal ring

  11. What would be your initial plan? Stop Here and Discuss

  12. The Gastroenterologists Chose to: • Stop the H2 receptor antagonist • Start PPI BID • Obtain Esophagogastroduodenoscopy (EGD)

  13. Mr. Rendly’s EGD Findings: Esophagus:- Distal 5 cm with 4 linear erosions - Benign appearing 12mm diameter stricture at 39 cm Stomach:- Normal except 3 cm hiatal hernia Duodenum:- Normal

  14. Biopsies of the Stricture: • Revealed Benign Squamous Mucosa with Inflammatory Changes • The stricture was dilated to a diameter of 17 mm over 2 sessions one week apart.

  15. Mr. Rendly returns two weeks after the second esophageal dilation. He no longer has dysphagia. He denies heart- burn and regurgitation. Presently, he is still on the PPI in BID dose.

  16. Now, what would you do? Stop Here and Discuss

  17. More Than One May be Appropriate • Maintain current therapy indefinitely • Taper PPI to once a day for two to three months and then switch to maintenance H2 receptor antagonist and/or Cisapride • Discuss anti-reflux surgery with him • Test and treat for H. pylori before using long-term PPI • Taper PPI to once daily and maintain indefinitely

  18. Treatment Plan Recommendedby the Gastroenterologists: • Taper PPI to once daily and maintain indefinitely • Discuss anti-reflux surgery as an appropriate alternative to long-term medical therapy

  19. Do these decisions differ from yours? What is the rationale for your choice? Stop Here and Discuss

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