WBR1030

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office, MainCategory::Inpatient Facilities
Sub Category	SubCategory::Gastrointestinal, SubCategory::Oncology
Prompt	[[Prompt::A 46 year old male comes to his primary care physician with complaints of intermittent chest pain and difficulty in swallowing for the past 10 days. He denies any history of radiation of pain, difficulty in breathing, loss of appetite and loss of weight. He has a past medical history of gastroesophageal reflux disease for the past 5 years and is on treatment with proton pump inhibitors. He is also a known hypertensive and diabetic patient who is regular with his medications. He is a known smoker who quit smoking before 2 years and occasionally drinks alcohol. His vital signs are heart rate of 82 beats/min, respiratory rate of 16/minute, blood pressure of 130/80 mm Hg and oral temperature of 37.2 C. The patient is referred for an endoscopy where biopsies are taken from all the four quadrants within every 2 cm epithelium in the lower esophagus. The histopathology of the biopsies revealed a low grade dysplasia of the esophageal epithelium. What is the next best step in management of this patient?]]
Answer A	AnswerA::Repeat endoscopy after 6 months
Answer A Explanation	AnswerAExp::'''Incorrect'''-Repeat endoscopy after 6 months is only recommended for metaplasia.
Answer B	AnswerB::Continue with proton pump inhibitors
Answer B Explanation	[[AnswerBExp::Incorrect-In a GERD patient who has progressed to Barret's esophagus, a decision on endoscopic surveillance and appropriate surgical management will be the next best step although the patient will be continuing his proton pump inhibitors.]]
Answer C	AnswerC::Repeat endoscopy after 1 year
Answer C Explanation	AnswerCExp::'''Correct'''-Endoscopic surveillance every 1 year is recommended for low grade dysplasia in order to monitor the progression of the disease.
Answer D	AnswerD::Esophagectomy
Answer D Explanation	AnswerDExp::'''Incorrect'''-Esophagectomy is recommended for high grade dysplasia.
Answer E	AnswerE::Endoscopic ablation of the lower esophageal mucosa
Answer E Explanation	AnswerEExp::'''Incorrect'''-Endoscopic ablation of the lower esophageal mucosa may be helpful in managing high grade dysplasia.
Right Answer	RightAnswer::C
Explanation	[[Explanation::Gastroesophageal reflux disease (GERD) is a disease with chronic symptoms due to damage to the esophageal mucosa as a result of abnormal reflux of acidic stomach contents into the esophagus. Chronic GERD is associated with an increased risk of Barrett's esophagus which is a premalignant condition of the esophageal mucosa which is in turn associated with an increased risk of adenocarcinoma of the esophagus. Upper GI endoscopy is recommended in patients with 1. Heartburn and alarm features like dysphagia, odynophagia, gastrointestinal bleeding, anemia, weight loss, and recurrent vomiting, to rule out the complications of GERD and other diagnoses. 2. Typical GERD symptoms that persist despite a therapeutic trial of four to eight weeks of twice daily proton pump inhibitor therapy. 3. Severe erosive esophagitis on initial endoscopy where a follow-up endoscopy after a two month course of proton pump inhibitor therapy to assess healing and to rule out Barrett's esophagus. 4. Older than 50 years with chronic GERD symptoms and additional risk factors for Barrett's esophagus and esophageal adenocarcinoma. Since the patient undergoes an upper GI endoscopy and its biopsy specimen reveal a low grade dysplasia, a progression of the disease to Barrett's esophagus is diagnosed. Barrett esophagus requires the following endoscopic surveillance. Repeat endoscopy in 1 year for low grade dysplasia and repeat endoscopy in 6 months for metaplasia. High grade dysplasia is usually treated with esophagectomy to prevent its progression to frank adenocarcinoma. Educational Objective: GERD progressed to Barrett's esophagus requires appropriate endoscopy surveillance and treatment. Endoscopic surveillance every 6 months is recommended for metaplasia, every 1 year for low grade dysplasia and esophagectomy is recommended for high grade dysplasia. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Gastroesophageal reflux disease, WBRKeyword::GERD
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