A 42-year-old woman from the Philippines comes to the office with abdominal pain for the last 4 months. The patient describes intermittent episodes of dull epigastric pain that usually start when she skips a meal. She often drinks a glass of lactose-free milk or takes acetaminophen to ease the symptoms. The patient also describes bloating after eating certain types of food. Her medical history includes diet-controlled type 2 diabetes mellitus.
Blood pressure is 142/89 mm Hg and pulse is 88/min. BMI is 31 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:
Abdominal ultrasound shows several gallstones 3-4 mm in diameter.
Which of the following is the best next step in management of this patient?

Question

A 42-year-old woman from the Philippines comes to the office with abdominal pain for the last 4 months. The patient describes intermittent episodes of dull epigastric pain that usually start when she skips a meal. She often drinks a glass of lactose-free milk or takes acetaminophen to ease the symptoms. The patient also describes bloating after eating certain types of food. Her medical history includes diet-controlled type 2 diabetes mellitus.
Blood pressure is 142/89 mm Hg and pulse is 88/min. BMI is 31 kg/m². Physical examination is unremarkable.
Laboratory results are as follows:

Abdominal ultrasound shows several gallstones 3-4 mm in diameter.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9809_a838_853d_c98871c8291a_MD0002_00 This patient's symptoms are suggestive of dyspepsia, which is characterized by epigastric discomfort, postprandial fullness, and/or early satiety. Most cases of dyspepsia are functional (idiopathic), but organic causes include gastroesophageal reflux, peptic ulcer disease, gastric malignancy, and nonsteroidal anti-inflammatory drug gastropathy. Pain that occurs on an empty stomach is usually due to the continued secretion of gastric acid after completion of meal digestion and suggests peptic ulcer disease. Helicobacter pylori infection is the most frequent cause, and any patient age <60 with dyspepsia and without compelling indication for upper gastrointestinal endoscopy (eg, significant weight loss) should receive stool antigen or urea breath testing. Although abdominal ultrasound shows gallstones, this patient does not have a typical biliary pattern of symptoms (ie, right upper-quadrant pain lasting ≥1 hour that is triggered by a fatty meal, diaphoresis, nausea, vomiting). Asymptomatic gallstones are frequent and other more likely causes of this patient's dyspepsia should be addressed first (Choices B and E). (Choice A) Patients with celiac disease typically experience fatigue, iron deficiency anemia, nutritional deficiencies, and symptoms of malabsorption (eg, diarrhea, steatorrhea, flatulence) following gluten intake. (Choice C) Gastroparesis occurs in patients with long-standing (eg, >5 years) diabetes mellitus and is most commonly seen in those with renal, ocular, or neurologic involvement. Symptoms occur after eating and not when meals are skipped. Educational objective: Dyspepsia is usually idiopathic but may be due to gastroesophageal reflux disease, nonsteroidal anti-inflammatory drugs, or peptic ulcer disease. Asymptomatic gallstones are common and may coexist with dyspepsia but do not require treatment. __________ References: Risk assessment in cholelithiasis: is cholecystectomy always to be preferred? (http://www.ncbi.nlm.nih.gov/pubmed/20502977) Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. (http://www.ncbi.nlm.nih.gov/pubmed/27707777) ACG and CAG Clinical Guideline: Management of Dyspepsia. (http://www.ncbi.nlm.nih.gov/pubmed/28631728)

A 42-Year-Old Woman from the Philippines Comes to the Office