Recalcitrant Gastroesophageal Reflux Disease in the Setting of a Gastroesophageal Junction Mass

Abstract

In this case study, a sixty-three year old African American female with significant past medical history postsurgical hypothyroidism, hypertension, gastroesophageal reflux disease (GERD) presented with ongoing complaints of severe retrosternal burning associated with regurgitation. She had severe typical GERD symptoms despite twice a day PPI therapy. She had pH impedance testing on therapy which revealed abnormal esophageal acid exposure on therapy(>2.4% total esophageal acid exposure time). She underwent esophagogastroduodenoscopy (EGD) to evaluate for a source for her symptoms which revealed a freely prolapsing mass at the gastroesophageal junction. The location and dimension of the mass compromised the lower esophageal sphincter (LES) leading to her recalcitrant GERD. The patient was scheduled for laparoscopic Nissen fundoplication with transgastric resection of the gastric mass. Pathology of the intra gastric mass indicated benign sub-epithelial simple cyst. Overlying squamocolumnar junction mucosa with changes suggestive of GERD. At two weeks post op, she was significantly better. She had resolution of her previous symptoms and was no longer taking her PPI. She reported no significant dysphagia and no abdominal pain.Figure 1Discussion: Recalcitrant GERD is a common diagnostic dilemma that gastroenterologist evaluate. This case illustrates a novel cause of recalcitrant GERD secondary to benign sub-epithelial simple cyst creating lower esophageal sphincter incompetence which improved after resection. This case underscores the importance of EGD in patients who fail medical therapy.