A 35-year-old woman comes to the office due to postprandial fullness, early satiety, and epigastric pain for the past 6 months. She has had no blood in the stool or melena. The patient has not lost weight. Two months ago, she started treatment with over-the-counter omeprazole for 2 weeks but discontinued after noticing only minimal improvement. Medical history includes generalized anxiety disorder. The patient takes no regular medications. Her mother was diagnosed with colon cancer at age 62.
Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 76/min. Physical examination is within normal limits except for mild epigastric tenderness.
Initial laboratory results are as follows:
Which of the following is the best next step in management of this patient?

Question

A 35-year-old woman comes to the office due to postprandial fullness, early satiety, and epigastric pain for the past 6 months.  She has had no blood in the stool or melena.  The patient has not lost weight.  Two months ago, she started treatment with over-the-counter omeprazole for 2 weeks but discontinued after noticing only minimal improvement.  Medical history includes generalized anxiety disorder.  The patient takes no regular medications.  Her mother was diagnosed with colon cancer at age 62.
Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 76/min.  Physical examination is within normal limits except for mild epigastric tenderness.
Initial laboratory results are as follows:
 Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9802_5523_853d_11399a1e3f62_MD0002_00 This patient has dyspepsia (ie, postprandial fullness, early satiety, epigastric pain) without nonsteroidal anti-inflammatory drug use or symptoms of gastroesophageal reflux (eg, regurgitation). Given her age <60, noninvasive testing for Helicobacter pylori is warranted, allowing for the avoidance of unnecessary endoscopic procedures. Tests for active infection include the urea breath test or stool antigen testing; if positive, appropriate antibiotic therapy is started. Antisecretory therapy, including proton pump inhibitors such as omeprazole, decreases the sensitivity of these tests and, if possible, should be withheld for 2 weeks prior to testing. In patients unable to stop proton pump inhibitors, H pylori serology may be considered, as a negative test is likely to reflect a true absence of infection. However, serology should generally be avoided due to its inability to distinguish between active and past infection and the need for confirmatory testing (ie, stool antigen testing) to avoid treating patients with false-positive results. (Choice A) A CT scan would be indicated in patients with palpable masses or suspicion for other structural disorders. Imaging findings in patients with uncomplicated dyspepsia would most likely be normal or nonspecific. (Choice B) Symptoms alone have low specificity for H pylori, and patients should have confirmation testing prior to initiating antibiotic therapy. (Choice C) A trial of acid suppression should be pursued if H pylori testing is negative but should not be attempted for dyspepsia until H pylori status has been evaluated. (Choice E) Upper gastrointestinal endoscopy is indicated for patients age ≥60 or on a case-by-case basis in those age <60 with significant concerning features (eg, significant weight loss, unexplained iron deficiency anemia). Educational objective: Patients with dyspepsia who have not used nonsteroidal anti-inflammatory drugs, who have no symptoms of gastroesophageal reflux, or who are age <60 should undergo urea breath testing or stool antigen testing to evaluate for Helicobacter pylori infection and determine further therapy. __________ References: ACG and CAG clinical guideline: management of dyspepsia. (http://www.ncbi.nlm.nih.gov/pubmed/28631728)

A 35-Year-Old Woman Comes to the Office Due to Postprandial