Setting: office
CC: “My stomach hurts.”
VS: BP: 118/86 mm Hg; P: 84 beats/minute; T: 97.8° F; R: 16 breaths/minute
HPI: A 43-year-old infectious diseases doctor visits to your office complaining of epigastric pain over the past few weeks. The patient is extremely tense, undergoing a divorce, and has been having increasing epigastric pain despite the use of H2-blockers and liquid antacids at first and now omeprazole.
What is the most common cause of epigastric pain?
a. GERD
b. Nonulcer (functional) dyspepsia
c. Duodenal ulcer
d. Gastric ulcer
e. Gastritis
Answer b. Nonulcer (functional) dyspepsia
Fifty to ninety percent of epigastric pain is functional dyspepsia and no etiology is ever found. Ulcers make up only 10% to 15% of epigastric pain. Nonulcer dyspepsia is like a tension headache. It is, by far, the most common cause of the pain and nothing of the mechanism is clear.
PMHX: none
Medications: omeprazole only
“Alarm symptoms” indicating urgent endoscopy:
• Weight loss
• Blood in stool or anemia
• Dysphagia
ROS:
No weight loss
No blood in stool
No dysphagia
Which is reliably associated with tenderness on examination?
a. Duodenal ulcer
b. Pancreatitis
c. Gastric ulcer
d. Nonulcer dyspepsia
Answer b. Pancreatitis
Only pancreatitis is routinely associated with epigastric tenderness. Ulcer disease is tender only about 10% of the time.
PE:
General: anxious, well-built muscular man
Abdomen: soft, nontender
Initial Orders:
Upper endoscopy
Gastroenterology evaluation
Continue omeprazole
When is “scope” the answer for epigastric pain?
• Alarm symptoms
• Bleeding
• Age >45 to 55 years
• Symptoms not resolving with PPIs
Upper endoscopy shows a large gastric ulcer. A biopsy is obtained for H. pylori. The rapid urease test is positive for Helicobacter.
How is a gastric ulcer managed differently than a duodenal ulcer?
a. PPIs are not used.
b. Repeat the endoscopy and do a biopsy in 4 to 8 weeks.
c. Treat H. pylori.
Answer b. Repeat the endoscopy and do a biopsy in 4 to 8 weeks.
A gastric ulcer is associated with cancer. A duodenal ulcer is not associated with cancer. Re-scope the gastric ulcer to be sure it has resolved and there is no cancer. The indication for endoscopy in this patient was the failure of antisecretory therapy with PPIs.
Orders:
Continue PPI
Start amoxicillin and clarithromycin
Gastric ulcer: 4% cancer
Duodenal ulcer: 0% cancer
How does H. pylori survive in the acid of the stomach?
a. Flagella keeps it in the lumen of the stomach.
b. Bicarbonate production increases.
c. Urease makes ammonia to neutralize acid.
d. Urease inhibits the proton pump.
Answer c. Urease makes ammonia to neutralize acid.
Helicobacter has urease. Urease makes ammonia out of urea. Ammonia (NH3) binds acid (H+) and turns it into ammonium (NH4+). This is how acid is neutralized. That is the fundamental basic science you need to know about ulcers.
Helicobacter neutralizes acid with ammonia.
For which of the following is treatment for Helicobacter NOT indicated when found?
a. GERD
b. Duodenal ulcer
c. Gastric ulcer
d. Gastritis
e. Mucosa-associated lymphoid tissue lymphoma (MALToma)
Answer a. GERD
Helicobacter does not cause GERD. It is associated with all the others and is largely the causative organism.
Six weeks after therapy, the patient’s symptoms have resolved. Repeat endoscopy does not reveal evidence of ulcer or cancer. All patients with evidence of Helicobacter should be tested to confirm that it has been eradicated.
When positive, these tests indicate a current infection
• Breath testing
• Stool antigen