GASTROENTEROLOGY ARTICLE OF THE WEEK
February 28, 2007
Richter JE. How to manage refractory GERD. Nat Prac Gastroenterol Hepatol 2007;4:658-664.
1. Patients with refractory reflux (failure to respond to 4-8 week trial of omeprazole 20 mg) should:
a. be questioned about compliance and timing of PPI dose
b. be switch to a single evening dose or the same PPI prior to dinner
c. be switched to esomeprazole 40mg twice a day
d. be switched to omeprazole 20mg twice a day
e. be switched to esomeprazole 40mg once a day in the morning
2. In patients with suspected epidermolysis bullosa and abnormal endoscopic findings of the esophagus:
a. biopsy should not be obtained due to increased risk of perforation
b. biopsies of the abnormal mucosa will be sufficient to establish the diagnosis
c. both the normal and abnormal mucosa should be biopsied
d. immunofluorescent studies should be requested
e. esophageal dilation is contraindicated
True or False
3. 48-hr Bravo pH testing may be more sensitive than 24-hr catheter pH testing in diagnosing pathologic acid reflux while on PPI therapy.
4. Baclofen 5 to 20mg tid may help with non-acid reflux symptoms
5. A mid-esophageal discrete ulceration on a patient taking PPI’s and with a normal squamo-columnar junction suggests Zollinger Ellison Syndrome
6. Most patients with “refractory GERD” will have esophagitis on endoscopy
7. All currently available PPI’s are metabolized through the CYP2C19 p450 cytochrome
8. pH testing for refractory GERD symptoms while on bid PPI should be done with the patient taking PPI during the pH study
9. Patients with functional heartburn are usually obese and have multiple health problems
10. Delayed gastric emptying is an important cause of “refractory GERD”
11. The classic endoscopic finding of pill-induced esophagitis are linear erosions in the distal esophagus surrounded by erythematous mucosa
12. Autoimmune dermatologic diseases that affect the esophagus may present with esophageal findings despite scant or no skin involvement
13. Changes in the CYP2C19 cytochrome activity can lead to rapid metabolizers who have a substandard response to omeprazole and lansoprazole
14. BID PPI’s eliminates gastric acidity at nighttime in virtually all patients