ROSH Gastrointestinal Practice Exam

What is the most appropriate next step for a woman with recurrent epigastric pain after heavy meals?

1. Ambulatory 24-hour pH monitoring

2. Empiric trial of omeprazole

3. Fundoplication

4. Upper endoscopy

The correct answer is: Empiric trial of omeprazole

The most appropriate next step for a woman experiencing recurrent epigastric pain after heavy meals is an empiric trial of omeprazole. This choice is based on the common presentation of gastroesophageal reflux disease (GERD) and the typical recommendation for managing such cases, especially when the symptoms suggest possible acid-related pathology. An empiric trial of a proton pump inhibitor (PPI) like omeprazole serves both diagnostic and therapeutic purposes. If the patient's symptoms improve with the medication, it suggests that the epigastric pain may be related to excess gastric acid or reflux. This approach is particularly reasonable in cases where there is a strong correlation between heavy meals and epigastric discomfort, indicating a potential link to acid secretion or reflux issues. Considering the other options, ambulatory 24-hour pH monitoring is usually reserved for more atypical cases or if the diagnosis of GERD is uncertain. Fundoplication is a surgical intervention typically applied only after medical management has failed, and upper endoscopy is generally recommended when there are alarming symptoms, such as weight loss, dysphagia, or gastrointestinal bleeding, or if there are no improvements with initial medical therapy. Since the case doesn't indicate alarming symptoms, starting with an empiric