A 60-year-old male, with a 10-year history of chronic heartburn, presents with worsening symptoms over the last 6 months. He experiences heartburn after meals, especially when lying down, and has recently noticed difficulty swallowing solid foods. He has unintentionally lost 10 pounds over the last 3 months. He reports taking over-the-counter antacids daily but finds minimal relief. He smokes 10 cigarettes per day and has a history of excessive alcohol intake, though he has cut back recently. His BMI is 25. Physical Exam Findings: General: Appears thin, mild pallor Abdomen: Soft, non-tender, no masses or organomegaly Cardiopulmonary exam: Normal Weight loss noted Initial Investigations: Alarm features (dysphagia, weight loss) suggest the need for endoscopy to evaluate for complications such as esophagitis, strictures, or Barrett's esophagus. MCQs: Which of the following is the most appropriate next step in his management? A) Start on high-dose PPIs and follow up in 6 months B) Refer for immediate endoscopy C) Increase the dose of antacids D) Recommend a strict diet and weight gain Which of the following is a possible complication of long-standing untreated GERD that might be seen on endoscopy? A) Barrett’s esophagus B) Diverticulitis C) Duodenal ulcer D) Gastric cancer Which lifestyle change would be most beneficial for this patient? A) Stop smoking B) Increase fluid intake C) Avoid all physical activity D) Gain weight Answers with Explanations: Answer: B) Refer for immediate endoscopy Explanation: Endoscopy is indicated for patients with alarm symptoms, such as dysphagia and weight loss, to evaluate for complications such as Barrett's esophagus or esophageal cancer. Answer: A) Barrett’s esophagus Explanation: Barrett’s esophagus is a precancerous condition associated with chronic GERD, where the normal esophageal lining is replaced by intestinal-type tissue. Answer: A) Stop smoking Explanation: Smoking cessation is a critical lifestyle modification for patients with GERD, as smoking reduces lower esophageal sphincter pressure, increasing the risk of acid reflux. Overview of the Topic: Severe GERD with Alarm Symptoms Severe GERD with alarm symptoms such as dysphagia, weight loss, or anemia requires urgent investigation with endoscopy to rule out complications such as Barrett’s esophagus, esophagitis, or esophageal cancer. High-dose PPIs can be initiated but must be combined with lifestyle changes and appropriate investigation. Key Learning Points: Endoscopy is essential for patients with alarm symptoms (dysphagia, weight loss). Barrett’s esophagus is a common complication of long-standing GERD. Smoking cessation and weight management are crucial lifestyle modifications for managing severe GERD.
