Case 19 - 39 yo with epigastric pain

Question 1

DDx for Abdominal Pain

Answer 1

GI: appendicitis, diverticulitis, GERD, dyspepsia, pancreatitis, obstruction
Cardiac: MI, angina, aortic dissection
Psychogenic
Pulm: Pleurisy, pneumonia
Renal: nephrolithiasis, pyelo, UTI
Other: abd wall strain, hernia, abscess, trauma

Question 2

Barriers to medical care for latinos

Answer 2

Undocumented, holistic view, less likely to seek care, view system as intimidating and confusing, masculinity “strong”

Question 3

Dyspepsia prevalence

Answer 3

25% of adults

Question 4

Dyspepsia etiology

Answer 4

Functional (non-ulcer), Peptic ulcer disease (PUD) (15-25%), GERD (5-15%), gastric/esophageal cancer

Question 5

PUD risk factors

Answer 5

Aspirin, NSAIDS, corticosteroids, cigarettes, stress, H. pylori

Question 6

Atypical sx of GERD

Answer 6

asthma, cough, globus, hoarseness, laryngitis

Question 7

GERD/PUD diff sx and timing wise

Answer 7

GERD is usually after large volumes, assoc with lying down or bending, also obesity
PUD is 5-15 mins after meals if gastric, made better by meals if duodenal (pain 4 hours later), can be assoc with nausea or vomiting

Question 8

Complications of GERD/PUD

Answer 8

GERD - esophagitis, barett’s esophagus, peptic strictures, adenocarcinoma
PUD - hemorrhage, perforation, ulcer scar healing/inflamm

Question 9

Alarm sx of GERD/PUD

Answer 9

dysphagia, early satiety, hematemesis, hematochezia, anemia, odynophagia, vomiting, weight loss

Question 10

H. pylori infection

Answer 10

Prevalence - rare in developed countries, 80-90% of adults in developing nations
Transmission - fecal-oral in childhood
MOA - lives in gastric mucosa, protected from host immune mechanisms, disrupts mucous layer, liberates enzymes and toxins, host immune response to h. pylori causes inflammation, can lead to chronic gastritis
Complications: PUD, gastritis, gastric carcinoma, lymphoma

Question 11

GERD physical exam

Answer 11

usually normal, look for anemia, volume status, signs of malignancy, gallbladder disease, hypo/hyperthroidism

Question 12

DDx epigastric pain in 39 yo male

Answer 12

More likely: Anxiety, GERD, PUD, abdominal wall muscle strain
Less likely: pancreatitis, pneumonia, diverticulitis, angina pectoris

Question 13

Dyspepsia studies

Answer 13

Upper GI - not useful for GERD, can help with ulcers
24 hr Ph probe - useful for GERD dx when no obvious or when pts don’t improve on PPI
FIT and FOBT - used if patient does not improve with PPI, FIT better for lower GI bleeding, FOBT better for upper GI bleeds
CBC - anemia but not sensitive/specific
H. pylori testing - serologic is good first time in population with high prevalence, urease breath test - detects active infection, less accurate during rx, Fecal antigen test - can evaluate eradication

Question 14

Management for GERD or PUD

Answer 14

1st treat with PPI or H2 blocker
Then Upper GI if no response to PPI, should do biopsy
Lifestyle - doesn’t do much but can’t hurt
If H.pylori rule out- can try TCAs, alternative therapy

Question 15

Management h. pylori

Answer 15

For H.pylori:
Triple therapy for 10-14 days: PPI, clarithomycin, amoxicillin (or metronidazole for those with pcn allergy)
Quadruple therapy for 10-14 days: PPI, tetracylcine, metronidazole, bismuth

Question 16

Do you test to prove h. pylori eradication?

Answer 16

If pts have h. pylori assoc ulcers, persistent sx, h. pylori assoc MALT, post gastric cancer, or clearance for resume NSAIDs

Question 17

How do you evaluate eradication?

Answer 17

Fecal antigen, if positive treat with salvage therapy

If fecal negative negative and pt still having sx, do urease breath test, if neg do Upper GI and biopsy