A 54-year-old lady presents to the clinic with heartburns. The heartburns are more when she goes back to her work after lunch. She has had these heartburns for 6 months and has been subjected to several upper GI endoscopies, which have been reported as normal.

Q. The immediate next step in her management is:

1. A resting EKG
2. A cardiac stress test
3. Esophageal manometry
4. 24 hour Esophageal pH measurement.

Answer: The answer is (a). 

This patient probably has anginal equivalent. Any discomfort in the chest area has to be viewed with suspicion especially when the patient is above 50 years of age and has other risk factors for coronary artery disease. A cardiac stress test right away might not be prudent as it is important to rule out an MI or acute coronary syndrome in the resting EKG.

Q. In a patient with gastro esophageal reflux disease, the indications for an upper GI endoscopy include all the following except

1. Poor response to medical treatment
2. Iron deficiency anemia
3. Patients requiring continuous maintenance therapy
4. Obese patients

Answer: The answer is (d). 

The definite indications for endoscopy in gastro esophageal reflux disease include poor response to medical treatment, patients with symptoms suggesting complicated disease such as dysphagia, odynophagia, occult or overt upper GI bleed, iron deficiency anemia, long standing maintenance therapy and to look for Barrett’s esophagus

Q. The following facts about gastro esophageal reflux disease are true except

1. After discontinuation of therapy relapse of symptoms occurs in 80% of the patients.
2. About 10% of the chronic reflux patients have Barrett’s esophagus.
3. Stricture formation is common (about 50%) with GERD
4. GERD most commonly presents as dysphagia

Answer: The answer is (c). After discontinuation of medical therapy recurrence rates of Gastro esophageal reflux symptoms is as high as 80%. About 10% of chronic reflux patients develop Barrett’s esophagus. Patients with Barrett’s esophagus are at risk of esophageal cancer. Stricture formation is not uncommon and it occurs in about 10%. The most common mode of presentation of GERD is dysphagia.