CASE
A 44-year-old man had postprandial heartburn and abdominal pain of 3 weeks' duration. Symptoms were relieved by OTC ranitidine 150 mg twice a day. The heartburn, which was associated with a sour taste in his mouth, intensified with spicy foods and when he lay supine. The abdominal pain was generalized and intermittent; he described it as burning and cramping sensations that radiated to his back. The patient rated the severity of the heartburn and abdominal pain at 7 (10 being the worst). He denied weight loss, fevers, chills, dysphagia, odynophagia, regurgitation, or melena.
History The medical history was significant for gastroesophageal reflux disease (GERD), duodenal ulcer, and diverticulitis. The patient had no allergies. Two years ago, after esophagogastroduodenoscopy (EGD), he was prescribed omeprazole 40 mg/d, which he took intermittently until he ran out 3 months ago. His symptoms recurred 3 weeks prior to this presentation. He was taking no other medications, including NSAIDs, aspirin, or vitamins. Surgical history included a left inguinal hernia repair. He denied consuming alcohol but said he had smoked a pack of cigarettes a day for 20 years. His mother's medical history was unknown; his father had coronary artery disease.
Physical examination The patient was overweight, afebrile, normotensive, and in no acute distress. The abdomen was nondistended; bowel sounds were active and without bruits but tympanitic to percussion. Hepatosplenomegaly was absent. Mild generalized tenderness was appreciated on light and deep palpation. There was no guarding, rigidity, referred pain, or rebound tenderness. The rectal examination was heme-negative.
Testing CBC with differential, chemistries, and amylase and lipase levels were all within normal limits. An IgA anti-tissue transglutaminase (anti-tTG) determination was negative. Abdominal ultrasonography findings were unremarkable.
The pathology report on tissue samples taken during EGD noted small-bowel mucosa with preserved villous architecture and gastric mucosa with mild chronic inactive gastritis, no Helicobacter pylori identified. In the esophagus, squamous mucosa showed no significant pathologic changes, while columnar mucosa demonstrated extensive intestinal metaplasia confirmed by positive findings with alcian blue/periodic acid-Schiff stain; no dysplasia was seen.
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