1. Case # 2 Mr. Rendly

2.  39 y/o w/m here for initial evaluation  CC: “heartburn symptoms after each meal” This started a year ago, mostly in response to spice foods. It has progressed in frequency and severity.  He sometimes wakes at night with regurgitation if he has eaten shortly before going to bed. He now sleeps on extra pillows.  He denies nausea, early satiety, bloating, cough, asthma, sore throat, chest pain, and voice changes.

3. Mr. Rendly PMH: Appendectomy at age 7 Medications: He took antacids briefly, but stopped because he didn’t like the taste. Allergies: None

4. Mr. Rendly Social History: Runs his own lawn and yard maintenance company Family History: Mother 65 y/o with osteoarthritis Father deceased at age 59 with esophageal carcinoma Two siblings and three children, all healthy ROS: Negative

5. Mr. Rendly’s PE HT:6’2”WT: 200 lb. BP: 140/82 P: 68 R:14T: 98.4º Well developed, well nourished HEENT: Normal oropharynx and mouth Neck: Normal Lungs: Clear to auscultation CV: S 1 and S 2 normal. No gallop or murmur

6. Mr. Rendly’s PE (continued) Abdomen: Nondistended, normal bowel sounds, no organomemgaly or masses. No tenderness Rectal: Normal with guaiac negative stool

7. Do you believe Mr. Rendly has GERD? Does he need a diagnostic study? Stop Here and Discuss

8. The Gastroenterology Panel Believes:  This presentation is typical for GERD  No diagnostic study is needed

9. What Is Your Differential Diagnosis? Stop Here and Discuss

10. Differential Diagnosis Developed by the Gastroenterologists: Most Likely:  GERD with esophageal stenosis  GERD with erosive esophagitis Less Likely:  GERD with Barrett’s Esophagus Least Likely:  Esophageal motility disorder  Esophageal carcinoma  Esophageal ring

11. What would be your initial plan? Stop Here and Discuss

12. The Gastroenterologists Chose to:  Stop the H2 receptor antagonist  Start PPI BID  Obtain Esophagogastroduodenoscopy (EGD)

13. Mr. Rendly’s EGD Findings: Esophagus:- Distal 5 cm with 4 linear erosions - Benign appearing 12mm diameter stricture at 39 cm Stomach:- Normal except 3 cm hiatal hernia Duodenum:- Normal

14.  Revealed Benign Squamous Mucosawith Inflammatory Changes  The stricture was dilated to a diameter of 17 mm over 2 sessions one week apart. Biopsies of the Stricture:

15. Mr. Rendly returns two weeks after the second esophageal dilation. He no longer has dysphagia. He denies heart- burn and regurgitation. Presently, he is still on the PPI in BID dose.

16. Now, what would you do? Stop Here and Discuss

17. More Than One May be Appropriate  Maintain current therapy indefinitely  Taper PPI to once a day for two to three months and then switch to maintenance H2 receptor antagonist and/or Cisapride  Discuss anti-reflux surgery with him  Test and treat for H. pylori before using long-term PPI  Taper PPI to once daily and maintain indefinitely

18. Treatment Plan Recommended by the Gastroenterologists:  Taper PPI to once daily and maintain indefinitely  Discuss anti-reflux surgery as an appropriate alternative to long-term medical therapy

19. Do these decisions differ from yours? What is the rationale for your choice? Stop Here and Discuss