A 58-year-old obese man presents to your clinic for follow-up of GERD. He has had reflux symptoms, characterized by heartburn and regurgitation, for more than 20 years. His reflux worsens when he is supine. His symptoms are generally well-controlled with once-daily PPI dosing, but he occasionally requires an on-demand second dose. Which of the following strategies would you recommend?
A. Refer for upper endoscopy to screen for Barrett esophagus
B. Refer for barium swallow to document GERD
C. Confirm presence of GERD with 24-hour pH study
D. Continue PPI therapy indefinitely and refer only if symptoms change
This patient has chronic GERD symptoms, which are generally well-controlled with a PPI. His supine reflux may be a result of laxity of his lower esophageal sphincter or a hiatal hernia, which can lead to more mucosal damage of his esophagus (ie, development of erosive esophagitis or Barrett esophagus). It is not clear when Barrett esophagus develops, but most recognized cases are diagnosed in patients in their sixth decade. A male predominance exists and a high BMI is a strong risk factor.
Although screening for Barrett esophagus is controversial, the American College of Gastroenterology supports screening in Caucasian men older than 50 with a long-standing history of GERD symptoms.