Question of the Week # 377

377)  A 42  year old man with no significant past medical is evaluated in your office for complaints of burning epigastric pain in his abdomen for the past 2 months. The pain 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 lives in New York City and has never traveled outside the United States.  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 athletic. 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) Obtain Upper GI Endoscopy

B) Obtain H.Pylori Serology by ELISA

C) Start Empiric trial with Omeprazole

D) Reassure because his dyspepsia is functional

E) Obtain H.Pylori Stool Antigen

20 Responses

  1. C) Start Empiric trial with Omeprazole – No alarming Sx

    • Why not Test and Treat approach?

      • If he does not respond to PPI then we can go ahead and do endoscopy.

      • By “Test and Treat”, I meant testing for H.Pylori. Why do you think it is not appropriate here?

      • Non Ulcer dyspepsia is the most common cause of Epigastric discomfort and he does not have any alarming Sx …so empirically treat him with PPI and if he does not respond we could do endoscopy and biopsy to rule out other causes like H Pylori

      • What are the indications for testing for H.Pylori in patients with Dyspepsia? What are the common ways of Testing?

        You have a conservative approach to empirically treating Dyspepsia which is acceptable in low-prevalence H.Pylori areas with prevalence less than 10% ( most of the USA) . This is the most cost-effective method in low prevalence areas but I feel this is not the answer they would want on the exam since American College of Gastroenterology prefers “Test and Treat approach” for all patients with dyspepsia. The approach recommended by ACG is to test for H.Pylori and teat if positive in all patients with dyspepsia. If H.pylori negative, they should just get empiric treatment with PPI trial ( If less than 55 years of age and with out warning symptoms ).

        If PPI trial fails or patients who do not respond to test and treat approach of H.Pylori or if warning symptoms or if age > 55 years ( 45 YEARS AGE CUT-OFF for patients with higher incidence of gastric cancers sucha sasians, hispanics and afro-carribbeans and those with family history) –> Endoscopy is indicated. Whenever there is an indication for endoscopy for whatever reason in Dyspepsia, H.Pylori testing must be performed by urease test on the biopsy specimen rather tahn additionally, doing a non-invasive h.pylori testing. Though Endoscopy is gold standard for H.Pylori diagnosis it is not indicated solely for purpose of diagnosing H.Pylori if there are no other acceptable indications to do it as a first step

      • Besides 25 -50% of general population have H.Pylori infection but most dont develop peptic ulcer disease…so don’t test for H.Pylori unless they have an ulcer,MALT or gastritis.

      • Again, this empiric trial is an acceptable approach in low prevalence areas. Old guidelines prior to 2005 favor empiric treatment with PPI rather than test and treat approach. Newer guidelines favor “Test and treat approach” as per position statement by AGA in 2005. However, like i mentioned, “test and treat” may not be a cost effective approach as number needed to test and treat to get symptom relief in non ulcer dyspepsia is 15 .
        The wording is important in the question. If they ask you initial approach go ahead with “Test and Treat”. If they ask you cost-effective approach, go ahead with “Empiric PPI trail” if the patient is from low prevalence H.Pylori area.

        Here is an AGA position statement for you to evaluate Dyspepsia : http://www.gastrojournal.org/article/S0016-5085(05)01817-2/fulltext

        Note that position statement notes “Empiric trial as most cost effective approach” but still recommends “Test and treat” as initial strategy.
        Here is also AAFP guidelines on this matter : http://www.aafp.org/afp/2011/0301/p547.html ( They kind of agree with AGA)

      • Thanks Dr.Red. This approach is from a reliable resource i was studying from…wow i’m scared now.

      • Again, this empiric trial is an acceptable approach in low prevalence areas. Old guidelines prior to 2005 favor empiric treatment with PPI rather than test and treat approach. Newer guidelines favor “Test and treat approach” as per position statement by AGA in 2005. However, like i mentioned, “test and treat” may not be a cost effective approach as number needed to test and treat to get symptom relief in non ulcer dyspepsia is 15 .
        The wording is important in the question. If they ask you initial approach go ahead with “Test and Treat”. If they ask you cost-effective approach, go ahead with “Empiric PPI trail” if the patient is from low prevalence H.Pylori area.

        Here is an AGA position statement for you to evaluate Dyspepsia : http://www.gastrojournal.org/article/S0016-5085(05)01817-2/fulltext

        Note that position statement notes “Empiric trial as most cost effective approach” but still recommends “Test and treat” as initial strategy.
        Here is also AAFP guidelines on this matter : http://www.aafp.org/afp/2011/0301/p547.html ( They kind of agree with AGA)

      • Thank you so much for the explanation!

  2. What’s the answer then?

    • Its

      E) Obtain H.Pylori Stool Antigen

      because serology cannot differentiate between old and new infections

  3. Start ppi

  4. i think serology for H.PYLORI

  5. Start Omeprazole now.

  6. test and treat….. stool antigen for h p, if pos them triple tx not only ppi.

  7. E

  8. B. As per AGA guidelines mentioned by usmlegalaxy, serologic test is most commonly used, but urea breath test is more accurate.

  9. This is what will happen in hospitals in 2014; everyone who is an adult and he is tested positive with ‘H pylori stool’ antigen and he has symptoms of dyspepsia will get antibiotics. Clarithromycin doesn’t work anymore, let’s see what is going to work and what is going to give way next. I resent the ‘new’ test and treat strategy. It means that anyone found with H pylori and dyspepsia will be bombarded with antibiotics until there is no H. Pylori in his/her stomach and no life form in his colon. This is gross abuse of recommender rights and antibiotics.
    ANTIBIOTICS IS NOT THE SOLUTION TO BOWEL COLONIZATION BY OPPORTUNISTIC ORGANISMS. PROBIOTICS AND PH MODIFIERS AND SPIRULINA AND OTHER BIO- COMPETITIVE AGENTS AND BIO-FIRMS SHOULD BE GIVEN A CHANCE BEFORE USING ANTIBIOTICS AGAINST BOWEL COMMENSALS. This is called PPI Trial.
    What evidence do we have that when there is dyspepsia, in the presence on H. Pylori, that 100% the origin is H. Pylori not functional dyspepsia or GERD or plain hyper acidity from plain over indulgence in acidic appetizers. By God I will not end up in a hospital if I hv stomach pain.
    But in the exam, and clinics, the chiefs will penalize if we don’t test every single patient who comes in for stomach pain, yes, everyone of them must have H. Pylori stool antigen test done. Standing order, if u find H.pylori by accident, destroy it. H.pylori is now the new Osama bin Laden on the lose and our only ammunition against it is antibiotics.

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