American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the next step for patients with gastroesophageal reflux disease whose symptoms did not respond to proton pump inhibitors?

1. Perform ambulatory pH impedance monitoring

2. Increase the dosage of proton pump inhibitors

3. Start a course of corticosteroids

4. Refer for surgery

The correct answer is: Perform ambulatory pH impedance monitoring

For patients with gastroesophageal reflux disease (GERD) whose symptoms do not improve with proton pump inhibitors (PPIs), the next appropriate step is to perform ambulatory pH impedance monitoring. This diagnostic test measures both acid and non-acid reflux episodes in the esophagus, providing valuable information about the frequency and duration of reflux events. The rationale behind this step is that it assesses whether the ongoing symptoms are indeed due to acid reflux that is resistant to PPIs or if there is another contributing factor. By confirming the underlying cause of the persistent symptoms, clinicians can tailor further management strategies effectively. This may include the potential need for alternative medical therapies or surgical options, based on the monitoring results. In contrast, simply increasing the dosage of PPIs may not address the symptoms if the reflux is not predominantly acid or if the source of the symptoms is different. Initiating corticosteroids is not a standard approach for GERD and would not usually be effective as a first-line intervention for reflux symptoms. Referring for surgery is typically considered only after confirming that a surgical option is necessary and appropriate, which cannot be determined without further clarification of the symptom etiology provided by the monitoring.