DDSEP® 8 Quick Quiz

March 2016 Quiz 1

Publish date: March 1, 2016

You are asked to see a patient in consultation for refractory GERD. The patient is a 44-year-old woman, admitted to the hospital for a urinary tract infection, who reports constant heartburn and regurgitation despite twice-a-day pantoprazole taken before breakfast and supper for the past 3 months. The patient is morbidly obese with a body mass index (in kg/m2) of 43, and suffers from diabetes and hypertension. Upper endoscopy demonstrates LA grade C erosive esophagitis on PPI therapy, a patulous gastroesophageal junction, and a 4-cm hiatus hernia.

Which of the following would you recommend?

A. Add sucralfate 1 gm q.i.d. to the regimen.

B. Change PPI dosing to intravenous.

C. Recommend Roux-en-Y gastric bypass.

D. Add metoclopramide 10 mg t.i.d. to the regimen.

E. Recommend lifestyle measures to complement PPI therapy.

Q1: ANSWER: C

Critique

The patient is morbidly obese, with persisting esophagitis despite twice-a-day PPI, and structural disruption of the gastroesophageal junction with a moderate-sized hiatus hernia and a patulous gastroesophageal junction. This is a setting in which a surgical approach is worthwhile. Since the patient is morbidly obese with hypertension and diabetes, the option of Roux-en-Y gastric bypass surgery is worth considering. This is a viable option for the surgical management of persisting reflux in the morbidly obese. Sucralfate has limited additive gain in persistent esophagitis despite PPI therapy. There is no net gain in switching the route of PPI administration to intravenous, and this is mostly indicated in the setting of gastrointestinal bleeding. Metoclopramide does not result in worthwhile augmentation of esophageal motility, and may not necessarily provide further symptom improvement or healing of esophagitis. Lifestyle measures complement pharmacologic management of reflux disease, but have not been shown to heal esophagitis.

Reference

1. De Groot N.L., Burgerhart J.S., Van De Meeberg P.C., et al. Systematic review: the effects of conservative and surgical treatment for obesity on gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2009;30:1091-102.

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