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Diagnostic Dilemma

Diagnostic Dilemma

A 66-year-old Asian woman presents with chronic heartburn and epigastric
discomfort. She has suffered with these symptoms most of her adult life and
underwent multiple upper gastrointestinal series in her homeland, China. The
radiologic studies were reportedly normal. She immigrated to the United States
several years ago, and her symptoms persisted and worsened recently. There is
no history of dysphagia or weight loss. She does not smoke or consume alcohol.
Her symptoms have continued despite treatment with a proton pump inhibitor.

Past history is unremarkable. Family history is positive for gynecological
cancer in her mother and lung cancer in her brother. Physical examination is
negative including stool guaiac.

1. The most appropriate approach to this patient is to:

a. Increase the dose of proton pump inhibitor
b.  Seek surgical consultation for antireflux surgery
c.  Perform upper gastrointestinal endoscopy
d.  Obtain an abdominal CT scan
e.  Treat for Helicobacter pylori

2. The photograph reveals:

a.  An ulcerated mass in the antrum of the stomach
b.  An esophageal tumor
c.  Linitis plastica
d.  Hiatal hernia
e.  Barrett’s esophagus


1. The correct answer is c. This patient with chronic intractable
heartburn and abdominal discomfort should undergo direct visualization of the
upper gastrointestinal tract. Endoscopy is the most sensitive and accurate
diagnostic tool in this setting. Increasing the dose of the proton pump
inhibitor would probably be ineffective and is associated with a risk of
obscuring a serious underlying process. Consideration of antireflux surgery,
abdominal CT scan, or empiric therapies for H pylori is premature without
further evaluation.

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