Question of the Week # 376

376)  A 56  year old Hispanic man with no significant past medical history presents to community health center with complaints of burning pain in his abdomen and bloating for the past 2 months. The pain is more is more in the epigastric area and is worse after eating and it is worse at night. He denies any chest pain or shortness of breath.  He takes over the counter antacids when the pain occurs and that seems to relieve the pain temporarily. He denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. He does not smoke or drink alcohol.   On examination, he is well-built. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative and complete blood count does not show any anemia. Which of the following  is the most appropriate next step?

A) H.Pylori antibodies

B) Trial of Proton Pump Inhibitors

C) Empiric therapy for H.Pylori

D) Ultrasound Gall Bladder

E) Endoscopy

11 Responses

  1. E) Endoscopy

  2. e

  3. E

  4. E) Endoscopy Age>45

  5. upper GIT endoscopy with biopsy

  6. i think so too, E but the only risk factor is the age so the tto w/ ppi?

  7. B) try PPIs

  8. ~B
    No wt loss, no occult blood, pain at night, antacids relieve symptoms temporarily. I think PPI trial being non-invasive would be first step.

    Only pt age leans toward endoscopy.
    I’ll go with PPI trial.

    Please correct me if I’m wrong.

    • the man is clearly past prescreening criteria by age so endoscopy only cause FOBT (-) if postive may have to chnage criteria and start with colonoscopy depeding of color and area found…. free to object any1

  9. E: age >55 years or alarm symptoms —-> endoscopy

  10. The most appropriate next step would be to do a PPI trial (and save this patient from spending $800) but the chiefs of gastroenterology would love to do an endoscopy on this patient right now, and so the correct answer is E. Think like a chief, this man will need an upper endoscopy anyway, we can better see the picture in the GEJ right now than after treatment. So do that or or stay in gastroenterology for one more week. The choice is yours.

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