American College of Physicians: Internal Medicine — Doctors for Adults ®

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The MKSAP Challenge

From the February ACP-ASIM Observer, copyright © 2003 by the American College of Physicians-American Society of Internal Medicine.

Editor's note: The following contains questions and answers excerpted from MKSAP 12 Update, a new enhancement to the College's popular self-assessment program. For more information on MKSAP 12 Update, contact ACP-ASIM Customer Service at 800-523-1546, ext. 2600, or 215-351-2600.

Clinical scenario

A 44-year-old man with a five-year history of gastroesophageal reflux disease (GERD) asks whether surgical management might be beneficial. His symptoms are controlled by taking a proton pump inhibitor each morning and occasionally in the evening as needed. The patient sleeps with the head of his bed elevated, remains upright after meals, does not smoke and rarely drinks alcoholic beverages.

Compared with ongoing medical management, which of the following may be a benefit of fundoplication for this patient?

A. Reduced risk of esophageal stricture
B. Reduced risk of esophageal carcinoma
C. Reduced need for acid reduction therapy
D. Improved control of symptoms


Answer: C

Educational objective: Recall the indications for surgical management of gastroesophageal reflux disease.

The major benefit of surgery for patients with gastroesophageal reflux disease (GERD) is a reduced need for acid reduction therapy. Although many patients still require medication postoperatively, the dose needed will be less than that needed for patients who have not undergone surgery.

Studies have demonstrated that the risk of developing esophageal strictures and carcinoma is not reduced in patients who undergo surgery compared with those who are managed medically. Studies have also shown that medical management and surgical management have similar efficacy in controlling symptoms of GERD.

References

1. Lundell L, Miettinen P, Myrvold HE, Pedersen SA, Liedman B, Hatlebakk JG, et al. Continued (five-year) follow up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. Journal of the American College of Surgery. 2001;192:172-9; discussion 179-81.

2. Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. Journal of the American Medical Association. 2001;285:2331-8.

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