MEDizzy - A 34-year-old man presents with substernal discomfort. The

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Gastroenterology

A 34-year-old man presents with substernal discomfort. The symptoms are worse after meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing, pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the patient has gained 20 lb in the past 2 years. Which of the following is the most appropriate initial approach?

ExplanationIn the absence of alarm symptoms (such as dysphagia, odynophagia, weight loss, or gastrointestinal bleeding), a therapeutic trial of acid reduction therapy is reasonable. Mild to moderate GERD symptoms often respond to H2 blockers. More severe dis-ease, including erosive esophagitis, usually requires proton pump inhibitor therapy for 8 weeks to ensure healing. If the patient has recurrent symptoms or has had symptomatic GERD for over 5 years, endoscopy may be indicated to rule out Barrett esophagus (intestinal metaplasia of the lower esophagus). Barrett's esophagus is a premalignant condition, and most patients receive surveillance EGD every 2 to 3 years, although evidence of mortality benefit from this approach is not available. In the absence of alarm symptoms, a therapeutic trial is generally favored over more expensive diagnostic studies (endoscopy, CT scan). Classic symptoms of GERD do not mandate an evaluation for coronary artery disease unless other features suggest this diagnosis.