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CASE 7.1

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A 43-year-old woman complains of a burning pain in the retrosternal area. Her symptoms started about 2 years ago and initially responded to self-medication with antacids or histamine-2 receptor antagonists (H2 blockers). However, within the last 4 months, she has had nearly daily problems. She frequently wakes up in the middle of the night with retrosternal, burning pain, radiating to her neck. She also frequently notices an acidic taste in her mouth. While antacids help somewhat, they only provide transient relief. She has otherwise been healthy. She currently takes up to 800 mg of cimetidine per day plus the antacids. She denies tobacco or alcohol use. Her physical examination is normal.

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Question 7.1.1 Which of the following is NOT considered a "red flag" when it comes to patients with acid reflux/dyspepsia?

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A) Weight loss.

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B) Trouble swallowing liquids.

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C) Trouble swallowing solids.

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D) A craving for doughnuts.

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Answer 7.1.1 The correct answer is "D." OK, we will give you this one. One of the most critical parts of patient assessment is to make sure there are no "red flag" symptoms that may indicate more than simple gastroesophageal reflux disease (GERD). Red flag symptoms include dysphagia, weight loss, anemia, aspiration, early satiety or vomiting, and cough. A craving for doughnuts is benign (although eating them is not) and may be seen among the book editors, police, college students, Vash the Stampede, and others.

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Question 7.1.2 Which of the following statements is true?

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A) All patients with GERD need endoscopy.

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B) Routine endoscopy in patients with GERD markedly reduces the risk of esophageal cancer.

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C) The diagnostic sensitivity and specificity of typical symptoms of GERD is >90%.

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D) Patients over the age of 45 with new onset symptoms are considered to be at high risk.

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E) C and D.

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Answer 7.1.2 The correct answer is "E." Because of the high sensitivity and specificity of symptoms (>90%), most patients do not need endoscopy or any other procedure or test to make the diagnosis of GERD. Patients with refractory GERD or those with new symptoms over the age of 45 years (50 by some sources) warrant endoscopy. "B" is incorrect. Screening for the presence of Barrett esophagus in patients with GERD is low yield. Targeted, not routine, endoscopy may be beneficial. Even then, the benefit is limited (J Natl Cancer Inst. 2011;103:1049). This is still a matter of active debate and recommendations may change.

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