A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 44-year-old man presents to the clinic with recurrent epigastric pain following meals for a month. He adds that the pain radiates up his neck and throat. Over the counter antacids have not helped. On further questioning, he endorses foul breath upon waking in the morning and worsening of pain when lying down. He denies any recent weight loss. His temperature is 37°C (98.6°F), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg. A physical examination is performed which is within normal limits except for mild tenderness on deep palpation of the epigastrium. An ECG performed in the clinic shows no abnormalities. What is the next best step in the management of this patient?
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A
Barium swallowIncorrect. Barium swallow has low sensitivity for GERD and is not a first-line diagnostic or therapeutic step; empiric PPI therapy is preferred in patients without alarm features.
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B
LansoprazoleCorrect. Lansoprazole is a proton-pump inhibitor — an empiric 8-week PPI trial is the recommended next step in a young patient with typical GERD symptoms and no alarm features.
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C
Liquid antacidIncorrect. Liquid antacids provide only brief, symptomatic relief and have already failed this patient; they do not address the underlying acid hypersecretion or heal esophageal injury.
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D
RanitidineIncorrect. Ranitidine (an H2-blocker) provides less potent acid suppression than a PPI and is reserved for milder or intermittent symptoms; it is also no longer routinely marketed due to NDMA contamination concerns.
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E
Upper endoscopyIncorrect. Upper endoscopy is reserved for patients with GERD alarm features (dysphagia, weight loss, bleeding, anemia, age >55) or failure of empiric PPI therapy — not as the initial step in a young patient with typical reflux symptoms.
↑ Tap an answer to reveal the reasoning
Answer: B. This 44-year-old man has classic gastroesophageal reflux disease (GERD): a month of postprandial epigastric pain radiating up to the neck and throat, worsening with recumbency, halitosis on waking, and incomplete relief with OTC antacids. He has no alarm features (no weight loss, dysphagia, hematemesis, melena, anemia, or age >55–60 with new symptoms), so endoscopy is not required up front.
For patients under 55–60 with typical GERD symptoms and no alarm features, current guidelines recommend an empiric 8-week trial of a once-daily proton-pump inhibitor (PPI). PPIs irreversibly inhibit the H+/K+-ATPase on gastric parietal cells, providing superior acid suppression compared with H2 blockers or antacids and effectively healing esophagitis. Lansoprazole is a PPI and is the next best step.
Antacids (already failed) and H2 blockers like ranitidine provide less potent acid suppression and are generally reserved for mild, intermittent symptoms or as on-demand add-ons. Barium swallow has poor sensitivity for GERD and is not the diagnostic test of choice — endoscopy would be used only if alarm features develop, symptoms fail PPI therapy, or surveillance for Barrett's is required. Lifestyle modifications (weight loss, elevating the head of the bed, avoiding late meals, alcohol, and trigger foods) should be recommended alongside the PPI trial.
**Why each option:**
**A.** Barium swallow has low sensitivity for GERD and is not a first-line diagnostic or therapeutic step; empiric PPI therapy is preferred in patients without alarm features.
**B.** Correct. Lansoprazole is a proton-pump inhibitor — an empiric 8-week PPI trial is the recommended next step in a young patient with typical GERD symptoms and no alarm features.
**C.** Liquid antacids provide only brief, symptomatic relief and have already failed this patient; they do not address the underlying acid hypersecretion or heal esophageal injury.
**D.** Ranitidine (an H2-blocker) provides less potent acid suppression than a PPI and is reserved for milder or intermittent symptoms; it is also no longer routinely marketed due to NDMA contamination concerns.