DDSEP Quick Quiz

DDSEP® 8 Quick Quiz - January 2018 Question 1

Q1. A 45-year-old woman underwent anti-reflux surgery 5 years ago for well-characterized reflux disease and a 5-cm hiatal hernia. After brief initial postoperative dysphagia treated conservatively with dietary adjustment, symptoms completely resolved. However, over the past 3 months, she has developed new dysphagia following solid meals, sometimes associated with epigastric pain. She localizes the dysphagia to the retrosternal region, with infrequent regurgitation but no heartburn.


Which of the following is the most appropriate next step?

Upper endoscopy

Omeprazole once a day

pH study off PPI

Esophageal manometry

Barium swallow

Q1. CORRECT ANSWER: A

RATIONALE
In patients with a good response to anti-reflux surgery who develop new dysphagia, an upper endoscopy is the test of choice. This will evaluate the structural integrity of the fundoplication, and evaluate for disruption and paraesophageal herniation. The esophagus can be inspected for esophagitis, and dilation of the fundoplication site can be performed. In the absence of heartburn or the original reflux symptoms, empiric acid suppression is not expected to improve the dysphagia. If the endoscopy is negative, esophageal manometry and barium swallow are the next studies of value. A pH study off PPI therapy is performed if recurrent reflux is suspected that does not respond to anti-reflux medications.

REFERENCE
1. Johnson D.A., Younes Z., Hogan W.J. Endoscopic assessment of hiatal hernia repair. Gastrointest Endosc. 2000;52(5):650-9.

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