This document presents a case study of a 31-year-old female patient complaining of worsening heartburn impairing her quality of life for the past year. A trial of PPI therapy provided marked improvement in her symptoms. Two months later, her symptoms recurred, and an endoscopy showed a small hiatal hernia with no signs of reflux and positive H. pylori infection. Ambulatory pH monitoring showed pathological acid reflux. She was treated for H. pylori and maintained on PPI therapy, but complained of increased nocturnal heartburn on step-down therapy. The document discusses various treatment approaches and indications for surgery.

1. Acid related disorders
Case presentation
Hossam Ghoneim, MD

2. Case 1
• Female patient, 31 yrs old
• Complaining of heartburn which has been
progressively increasing and impairing her
quality of life for the past year especially that
she commonly suffers bouts of nocturnal
heartburn.
• She is not suffering any dyspeptic symptoms,
upper abdominal pain or vomiting.
• She has no medical history of concern

3. • On examination
– Normal vital signs
– No organomegally or abdominal tenderness
– BMI 32
– Normal chest and heart examination

4. Q1: What to do next?
1. Upper GI endoscopy
2. Laboratory investigations
3. Abdominal ultrasound
4. Prescribe PPI and follow up
5. Ambulatory PH monitoring

5. Diagnostic Approach
• Symptom analysis
• PPI therapeutic trial
• GI Endoscopy
• Ambulatory PH monitoring, preferably
Multichannel intraluminal impedance MII

6. PPI for Diagnosis
• “ This is what happens in the community.
Most patients have a trial of PPI therapy. So I
think we have to accept that as being the
standard approach today. If it‘s successful you
basically have confirmed your diagnosis

7. • The patient was given a trial of PPI therapy
40mg once
• Follow up after 2 weeks showed marked
improvement in her symptoms

8. Q2: what to do next?
1. Stop treatment, advise life style modification
and F/up
2. Taper PPI gradually in an attempt to stop
treatment and F/up
3. Continue PPI for life
4. Perform UGI endoscopy

9. • The patient was weaned off her PPI gradually
over 4 weeks and advised to return for f/up in
case of recurrence of HB.

10. Q3: When to do endoscopy?
1. Failuire of PPI therapeutic trial
2. Pts with alarming features at presentation
3. Pts previously endoscoped and known to
have grade C or D GERD (every 2 months)
4. Pts older than 50 yrs with risk factors for BE
and/or Oesophageal adenocarcinoma
5. Chronic pts who report unusual
disappearance of HB on no treatment
6. All of the above

11. • All of the above are the true indications for
UGI endoscopy in suspected or established
GERD pts.
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological
Association Institute technical review on the management of
gastroesophageal reflux disease. Gastroenterology 2008; 135:1392.

12. • Two months later the patient reports
recurrence of debilitating HB with increased
incidence of nocturnal bouts
• UGI endoscopy was performed showing
– Hiatal hernia about 3cm with no endoscopic signs
of reflux
– Random antral biopsy was +ve for H. Pylori using
CLO test

15. Q4: At this point
• Do you consider an established diagnosis of
NERD and put the patient on a maintenance
therapy scheme?
• Perform Ambulatory PH monitoring?
• Would you treat her H. Pylrori infection?

16. H. Pylori

17. • Ambulatory PH monitoring was performed
showing pathological reflux.
• Patient was prescribed PPI 40 mg for two
months within which a sequential treatment
for H. pylori was included
• Her response was satisfactory but on initiating
an ODT approach she complained of inceasing
incidence of nocturnal HB

18. Q5: Step down or Step up therapy?
• Step up approach, initial life- style changes,
use of antacids, H2- receptor antagonists
(such as ranitidine 150mg x 2) and, finally, if
symptoms persist, switch to PPI
• Step down approach, treatment is initiated
with a PPI 20mg or 40mg, and subsequent
maintenance treatment is stepped down to a
regimen that effectively controls pts
symptoms (10 or 20mg).

19. • Step-down therapy was superior and showed
a statistical significance over the step-up
approach (71% compared to 42% of 92
patients) in controlling patients symptoms
both initially and on 4 and 8 weeks follow up.
K.H. Katsanos,et. al; Comparison of the ìstep downî & ìstep upî approach
in treatment of pts with symptomatic gastro-esophageal reflux disease (GERD):
Results of a randomized open-label pilot study with omeprazole in Northwest
Greece ANNALS OF GASTROENTEROLOGKY.H2. K00A3T, 1S6A(2N)O:1S38, e-1t5a0l

20. Maintenance therapy
• 2/3 of NERD pts and nearly all pts of GERD will require
long term ttt, however, there must be a trial to stop ttt;
except in LA grade C & D, and pts with BE.
• For patients who require long-term PPI therapy, the
lowest effective dose to is be used.
• While ODT has been associated with higher patient
satisfaction as compared with continuous therapy in
pts with GERD, a systematic review of 3 RCTs concluded
that continuous therapy provided better symptom
control, quality of life, and higher endoscopic remission
rates.
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association
Institute technical review on the management of gastroesophageal reflux disease.
Gastroenterology 2008; 135:1392.

21. Q6: For nocturnal acid breakthrough
1. Divide the PPI dose 20mg in the morning and
20mg at bed time?
2. Double the PPI dose 40mg in the morning
and 40mg at bed time?
3. Add an H2R blocker at night?
4. Add a prokinetic?

22. Nocturnal Acid Break through
Known tolerance to H2 receptor blockers

23. Drugs other than PPI’s
• Prokinetics: Domperidone, Itopride, etc.,
• No concrete evidence of any effectiveness!!

24. However, we need to think out of the
PPI box

25. • Eventually, the patient was well maintained on
20mg PPI daily dose with infrequent
insignificant skipped doses.
• However, she came back to ask for an end to
her daily commitment to medications and was
even willing to undergo surgery, if we advised.

26. Q7: When to do surgery?
1. Failure of medical treatment
2. Good response to medical treatment but
failure to comply
3. Presence of a hiatal hernia (is there a cut-off
size for hiatal hernia needing repair)
4. Barrett’s oesophagus per se
5. BE with progressive dysplasia

27. THANK YOU