Patient Presentation
A 45-year-old man presents with several months of chronic heartburn, regurgitation, and a sour taste in his mouth, worse after meals and when lying down. He also reports occasional chest pain and difficulty swallowing.
He has been taking over-the-counter antacids intermittently with only partial relief. His symptoms disturb his sleep, and he wakes at night with acid regurgitation.
You are asked to evaluate him and formulate a workup and management plan. His presence of chest pain and dysphagia raises concern for something beyond simple reflux and must be addressed before committing to a GERD diagnosis.
What You'll Be Asked — and What a Strong Resident Discusses
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How do you categorize this patient's symptoms and what is your initial approach?
Expected answer
GERD symptoms are divided into esophageal (heartburn, regurgitation, chest pain, dysphagia) and extra-esophageal (cough, laryngitis, asthma, dental erosion) per the Montreal Classification. This patient has classic symptoms (heartburn, regurgitation) but also atypical/alarm symptoms — chest pain, dysphagia. I take a focused history including timing, duration, provoking factors, sleeping habits, and OTC medication use. The alarm symptoms mean I cannot simply start empiric therapy; they mandate objective workup.
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He has chest pain. What must you do before attributing it to reflux?
Expected answer
Cardiac etiology must be ruled out first — this chest pain could be angina/ACS. I would obtain an ECG and appropriate cardiac evaluation before ascribing chest pain to GERD. Missing a cardiac cause is a fatal error.
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He has dysphagia. Why does this change your workup?
Expected answer
Dysphagia is NOT a classic GERD symptom and is an alarm symptom concerning for stricture, malignancy, achalasia, or other mechanical/motility pathology. It mandates early upper endoscopy and barium esophagram to rule out intraluminal pathology, mechanical obstruction, and mucosal disease. I would not treat empirically with PPIs and dismiss the dysphagia.
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For a patient with only classic symptoms and no alarm features, what is the initial management?
Expected answer
Lifestyle modification and empiric medical therapy. Lifestyle changes: weight loss if BMI >25, elevating the head of the bed (especially for nocturnal reflux), avoiding meals within 2–3 hours of reclining, and avoiding personal triggers (tobacco, alcohol, chocolate, caffeine, spicy/citrus/carbonated foods) if they correlate with symptoms. Medically, start a once-daily PPI for 8 weeks, titrating to twice daily for partial responders.
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Describe medical management of GERD in detail.
Expected answer
PPIs are the most powerful and commonly used acid suppression. Start once-daily for 8 weeks; escalate to twice-daily if partially responsive. H2 antagonists are useful for symptom relief in patients without erosive esophagitis, especially nocturnal GERD. Antacids provide symptomatic relief. Patients whose symptoms resolve should be trialed off PPIs — exceptions are Barrett's esophagus and severe esophagitis, who stay on therapy. Inability to tolerate a trial off PPI warrants further workup.
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What are the indications for surgical referral in GERD?
Expected answer
1) Failure of medical management — partial PPI responders, severe regurgitation, or intolerance of PPIs. 2) Patient preference to avoid lifelong medication. 3) Severe/complicated GERD — Barrett's esophagus or peptic strictures. 4) Extra-esophageal symptoms. Objective evidence of reflux should be confirmed before offering surgery.
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What preoperative workup is required before antireflux surgery?
Expected answer
Upper endoscopy (assess mucosa, Barrett's, hiatal hernia), barium esophagram to delineate anatomy, and esophageal manometry to rule out achalasia/dysmotility and tailor the operation. Impedance-pH ambulatory reflux monitoring confirms abnormal acid exposure and symptom correlation if not already established. Catheter-based pH adds information on weakly acidic/nonacid reflux. Confirming pathologic reflux objectively is essential — don't operate on a normal esophagus.
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How does manometry guide choice of operation, and what are the surgical options?
Expected answer
With normal esophageal motility, options include Nissen (360°) fundoplication — the traditional gold standard — or magnetic sphincter augmentation (LINX, FDA-approved 2012, with good 5-year reflux control). With impaired motility, a partial (Toupet, 270°) fundoplication is preferred to reduce postoperative dysphagia. Toupet has equivalent heartburn control with lower dysphagia rates, and some advocate it routinely, obviating manometry. In patients meeting bariatric indications (BMI >35), Roux-en-Y gastric bypass is preferred as it treats reflux plus obesity-related comorbidities.
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A patient with GERD and BMI 42 asks about fundoplication. What do you recommend?
Expected answer
In obese patients meeting bariatric criteria, Roux-en-Y gastric bypass is the procedure of choice rather than fundoplication. It provides significant improvement in typical and atypical GERD symptoms while addressing obesity-related comorbidities. Fundoplication in the morbidly obese has higher failure rates due to increased intra-abdominal pressure.
What Residents Often Miss
- Attributing chest pain to GERD without ruling out a cardiac cause first.
- Dismissing dysphagia as part of GERD and starting empiric PPIs without endoscopy and barium esophagram to exclude malignancy, stricture, or achalasia.
- Proceeding to antireflux surgery without objective confirmation of pathologic reflux (pH monitoring) and without preoperative manometry.
- Performing a Nissen (360°) fundoplication in a patient with impaired esophageal motility, causing postoperative dysphagia — a partial (Toupet) wrap is indicated.
- Offering fundoplication to a morbidly obese patient instead of Roux-en-Y gastric bypass, leading to high recurrence rates.
- Failing to recommend lifestyle modification and an adequate PPI trial before jumping to surgical referral.
- Stopping PPIs in a patient with Barrett's esophagus or severe esophagitis rather than continuing long-term therapy.
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