patient presenting with atypical GERD...next step...scope or PPI ? - USMLE Forums
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  #1  
Old 08-16-2012
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GIT patient presenting with atypical GERD...next step...scope or PPI ?

A 58-year-old woman is evaluated in the emergency department for substernal chest pain of
18 hours' duration. She describes the pain as a tightening that is not associated with eating
or exertion and that radiates to the neck. The pain is not accompanied by dyspnea, nausea,
or diaphoresis and is not associated with exertion. She also reports symptoms of occasional
heartburn and acid regurgitation. She had a similar episode of substernal chest pain 1 month
ago, and an exercise stress test that achieved 90% her predicted maximal heart rate showed
no ischemia. The patient's medical history is otherwise unremarkable.
On physical examination, temperature is 37.2C (99.0F), blood pressure is 130/74 mm Hg,
pulse rate is 88/min, and respiration rate is 16/min; BMI is 32. The cardiopulmonary
examination is normal. Electrocardiography shows nonspecific ST-segment and T-wave
abnormalities, which are unchanged from several previous examinations.
Which of the following is the most appropriate management for this patient?
(A) Ambulatory esophageal pH monitoring
(B) Coronary angiography
(C) Esophagogastroduodenoscopy
(D) Oral proton pump inhibitor therapy
(E) Repeat exercise stress test
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  #2  
Old 08-16-2012
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I'd say scope, might have perforated, but then esophagram is alot better for it.
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  #3  
Old 08-16-2012
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Atypical chest pain with normal ECG (which would have been the first step for incoming patient), however the age is on the higher side hence (C) Esophagogastroduodenoscopy.
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Old 08-17-2012
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ans given is PPI !
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Old 08-17-2012
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why is not it Ambulatory PH monitoring ... EGscope may shows signs of reflux esophagitis but still not sesetive .. I think I have read before in MedStudy that young pts should have ambulatory PH monitoring ..
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Old 08-17-2012
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but I am not sure for elderly pts ... may be EGscope is useful as first diagnositic modality to be used in elderly pts to rule out dysplasia and malignancy
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Old 08-17-2012
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If I had such a question I would choose EGscope for elderly pts or for pts having longstanding symptoms (to rule out barret ) and I would choose PH monitoring for young pts with Atypical symptoms and ppi for young pts with typical symptoms
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Old 08-17-2012
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(A) Ambulatory esophageal pH monitoring - would be my choice, reason being shouldn't you evaluate a cause for this pain before prescribing meds?
(B) Coronary angiography NO reason
(C) Esophagogastroduodenoscopy No coz the onset is too acute to cause brret's / C.A. and GERD is more likely
(D) Oral proton pump inhibitor therapy Same doubt as for option (A), if we can give meds an relief kind of confirms the diagnosis, then this makes sense!
(E) Repeat exercise stress test , No point, no increase in pain with exertion anyways and a -ive test 1 month ago.

...
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Old 08-17-2012
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Quote:
Originally Posted by tyagee View Post
ans given is PPI !
Its surprising ...

In kaplan Surgury GI tract...
Vingnettes 1 & 2 -- Almost same type... Answer is GI scopy and biopsy then PPI..
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Old 08-18-2012
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Quote:
Originally Posted by cingulate.gyrus View Post
Its surprising ...

In kaplan Surgury GI tract...
Vingnettes 1 & 2 -- Almost same type... Answer is GI scopy and biopsy then PPI..
Why scope my friend with such an acute presentation? And also why not rule out/ rule in GERD by simple pH monitoring?
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Old 08-18-2012
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Quote:
Originally Posted by rocketprinciple View Post
Why scope my friend with such an acute presentation? And also why not rule out/ rule in GERD by simple pH monitoring?
Yes possible ....agreed....being presenting with acute symptoms rule out GERD with PH monitoring...But no PPI first...
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Old 08-18-2012
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Quote:
Originally Posted by cingulate.gyrus View Post
Yes possible ....agreed....being presenting with acute symptoms rule out GERD with PH monitoring...But no PPI first...
"but no PPI first... " Are you trying to ask WHY no PPI first?
Well , That's the ans i'm struggling to find myself as to why PPI is the right answer?
the best I can make of it as said above, is that a trial of PPI and relief, would confirm the diagnosis... Open to suggestions
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  #13  
Old 08-18-2012
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Quote:
Originally Posted by rocketprinciple View Post
"but no PPI first... " Are you trying to ask WHY no PPI first?
Well , That's the ans i'm struggling to find myself as to why PPI is the right answer?
the best I can make of it as said above, is that a trial of PPI and relief, would confirm the diagnosis... Open to suggestions
i wouldnt have bothered much but the source of question is very much authentic**. that what driving me crazy!
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  #14  
Old 08-19-2012
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I think as it is acute presentation Treatment first investigation later..
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Quote:
Originally Posted by cingulate.gyrus View Post
I think as it is acute presentation Treatment first investigation later..
Really? Even for GERD?
It says in the text though that you MUST check pH before you begin PPI, lest you should get False Negatives, What about that?
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  #16  
Old 08-19-2012
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e) repeat exercise stress test
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Old 08-19-2012
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Quote:
Originally Posted by tyagee View Post
i wouldnt have bothered much but the source of question is very much authentic**. that what driving me crazy!
No need to go crazy..........here is the explanation

Quote:
Noncardiac chest pain in the setting of spastic esophageal dysmotility often shows good response to antireflux therapy, even in the absence of typical gastroesophageal reflux symptoms. Reassurance and control of anxiety is extremely important in this setting. If antireflux therapy fails, alternatives include different classes of muscle relaxants mentioned above and pain modulators such as tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and trazodone. Some studies report positive results from behavior modification programs and biofeedback.
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  #18  
Old 08-19-2012
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MTB PAGE 244
((24 hrs pH monitoring is done to confirm diagnosis of GERD if the diagnosis is clinically not clear )) . so i think go forward to treat pt with PPI .
You are wright Novobiosin (Noncardiac chest pain may shows good response to antireflux therapy) .
so what ever the diagosis ( GERD or spastic esop dysmotility ) starting with PPI is good choice .
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Old 10-28-2012
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Quote:
Originally Posted by cingulate.gyrus View Post
I think as it is acute presentation Treatment first investigation later..
who taught you this principle?
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  #20  
Old 10-28-2012
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Quote:
Originally Posted by alex_ferguson View Post
who taught you this principle?
Why!!!!
U don't agree...

In case of trauma with severe pallor will u give blood transfusion or will wait for haemoglobin report to come..
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