Primer Question 1. A 42 year-old man has experienced frequent heartburn for the past 3 years. Recently, he was prescribed an 8-week trial of omeprazole 20 mg daily, which resulted in only partial relief of his heartburn. An endoscopy performed without stopping the omeprazole showed a normal-appearing esophagus. Biopsies from both the proximal and distal esophagus showed up to 6 eosinophils per high power field. Based on these data, which of the following is the most appropriate conclusion:
Incorrect. The correct answer is 4. PPIs are a treatment for both erosive esophagitis and EoE, and can eliminate the endoscopic and histologic features of both diseases. Consequently, it is inappropriate to make a diagnosis of NERD in an endoscopy performed for patients taking PPIs, since those patients might have erosive esophagitis that would apparent if PPIs were stopped. Similarly, EoE cannot be excluded in a patient taking PPIs. Indeed, the fact that both proximal and distal biopsies showed eosinophils in this patient (albeit less than the 15 eosinophils per high power field usually used as a cutoff to diagnose EoE) suggests that he may well have EoE that would be apparent if PPIs were stopped. Current ACG guidelines recommend stopping PPIs for 2 to 4 weeks prior to diagnostic endoscopy for patients with GERD symptoms that have not responded adequately to PPIs.
Ref: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Katz PO et al. AJG 2022:117:27
Correct. PPIs are a treatment for both erosive esophagitis and EoE, and can eliminate the endoscopic and histologic features of both diseases. Consequently, it is inappropriate to make a diagnosis of NERD in an endoscopy performed for patients taking PPIs, since those patients might have erosive esophagitis that would apparent if PPIs were stopped. Similarly, EoE cannot be excluded in a patient taking PPIs. Indeed, the fact that both proximal and distal biopsies showed eosinophils in this patient (albeit less than the 15 eosinophils per high power field usually used as a cutoff to diagnose EoE) suggests that he may well have EoE that would be apparent if PPIs were stopped. Current ACG guidelines recommend stopping PPIs for 2 to 4 weeks prior to diagnostic endoscopy for patients with GERD symptoms that have not responded adequately to PPIs.
Ref: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Katz PO et al. AJG 2022:117:27