A 62-year-old man is being evaluated for a 6-month history of occasional epigastric pain that is relieved by eating. The patient has tried over-the-counter antacids and ranitidine with some relief. He has had no dysphagia, weight loss, black stools, or blood in the stool. The patient has a 15-pack-year smoking history and drinks alcohol socially. He immigrated to the United States from China at age 12 with his family. He had a normal screening colonoscopy 2 years ago.
Blood pressure is 126/80 mm Hg, pulse is 81/min, and BMI is 24 kg/m². The abdomen is soft and nontender. Rectal examination reveals guaiac-negative stool. The remainder of the examination is normal.
Which of the following is the most appropriate management for this patient?

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Quizplus · Accepted Answer

11ec193a_97ee_58bf_853d_19f4e4563fad_MD0002_00 This patient has dyspepsia (ie, postprandial fullness, early satiety, epigastric pain), which is most commonly functional (idiopathic) with no detectable underlying cause. However, gastrointestinal malignancies and peptic ulcer disease also present with dyspepsia. The first step in evaluation is to determine whether the patient has reversible factors such as nonsteroidal anti-inflammatory drug use or typical symptoms of gastrointestinal reflux disease (GERD) (eg, retrosternal pain, regurgitation). Although patients with GERD and concomitant symptoms of dyspepsia may undergo a trial of acid suppression, those with dyspepsia alone require further evaluation (Choice D). Because of an increased incidence of upper gastrointestinal malignancy, patients age ≥60 with new-onset dyspepsia should undergo upper gastrointestinal endoscopy. Patients age <60 with alarm features (eg, family history of gastric cancer, unintended weight loss, dysphagia, gastrointestinal bleeding, iron deficiency anemia) should be assessed for the need for endoscopy on a case-by-case basis. Examples of patients who may warrant endoscopy include those with very prominent symptoms (eg, profound weight loss) or those with multiple alarm features. Patients in whom endoscopy is not initially indicated should be tested for Helicobacter pylori or undergo a trial of a proton pump inhibitor if testing is negative (Choice C). (Choice A) Abdominal ultrasonography is not routinely recommended for dyspepsia evaluation as gallstones may silently coexist in these patients. Jaundice in a patient with dyspepsia suggests a pancreatic or ampullary mass and should be investigated with more appropriate imaging (eg, MRI). (Choice B) A barium swallow study can be the appropriate initial evaluation in patients with dysphagia in the absence of dyspepsia. However, it is not sensitive for serious causes of dyspepsia and is reserved for patients who are unable to tolerate endoscopy due to comorbid conditions. Educational objective: Dyspepsia most frequently has no detectable underlying cause; however, it may be a sign of serious pathology (eg, malignancy, peptic ulcer disease). Patients age ≥60 with new-onset dyspepsia should undergo initial evaluation with upper gastrointestinal endoscopy, whereas those age <60 (without compelling indication for endoscopy) should be tested for Helicobacter pylori or receive a trial of acid suppression. __________ References: ACG and CAG clinical guideline: management of dyspepsia. (http://www.ncbi.nlm.nih.gov/pubmed/28631728)

A 62-Year-Old Man Is Being Evaluated for a 6-Month History