A 36-year-old man comes to the physician with daily epigastric pain for past 3 months. He has no vomiting, diarrhea, or weight loss. He has suffered from painful ulcers in his mouth once a year since he was a teenager. His only medications are a daily multivitamin and occasional ibuprofen for headaches. He does not use tobacco, alcohol, or illicit drugs. The patient emigrated from Taiwan 3 years ago. There is no family history of gastrointestinal malignancy or inflammatory bowel disease.
Examination is remarkable for mild epigastric tenderness. Stool is positive for occult blood.
His hemoglobin is 12.9 g/dL. Stool Helicobacter pylori antigen testing is positive. An upper endoscopy reveals no esophageal lesions and a solitary 1.4-cm ulcer with well demarcated edges in the antrum of the stomach.
Which of the following is the best next step in managing this patient?

Question

A 36-year-old man comes to the physician with daily epigastric pain for past 3 months.  He has no vomiting, diarrhea, or weight loss.  He has suffered from painful ulcers in his mouth once a year since he was a teenager.  His only medications are a daily multivitamin and occasional ibuprofen for headaches.  He does not use tobacco, alcohol, or illicit drugs.  The patient emigrated from Taiwan 3 years ago.  There is no family history of gastrointestinal malignancy or inflammatory bowel disease.
Examination is remarkable for mild epigastric tenderness.  Stool is positive for occult blood.
His hemoglobin is 12.9 g/dL.  Stool Helicobacter pylori antigen testing is positive.  An upper endoscopy reveals no esophageal lesions and a solitary 1.4-cm ulcer with well demarcated edges in the antrum of the stomach.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_980e_8a40_853d_6f971adbf4a5_MD0002_00 This patient presents with symptoms of peptic ulcer disease likely from Helicobacter pylori infection, a common cause of gastric and duodenal ulcers. Peptic ulcer disease is also strongly associated with gastric cancers (40%) and primarily gastric mucosa-associated lymphoid tissue lymphomas. H pylori infection also can lead to chronic gastritis and intestinal metaplasia and is more common in individuals from East Asia and certain parts of Latin America. Thus, obtaining multiple biopsies for histology is generally recommended. Eradication of H pylori (triple-based therapy) also appears to reduce the risk of gastric cancer in certain high-risk individuals. Endoscopy may be repeated in 6 weeks after completion of therapy if the ulcer biopsy was inadequate or in patients at high risk for malignancy (Table). (Choices B and C) This patient will benefit from a proton-pump inhibitor or H2-receptor antagonist as well as discontinuation of ibuprofen. However, the ulcer should be biopsied now to rule out metaplasia or dysplasia. Repeat endoscopy may be indicated if ulcer biopsies are not adequate. (Choice D) This patient has no symptoms of celiac disease (eg, unexplained anemia, weight loss, diarrhea, nutritional deficiencies) and does not need serum anti-transglutaminase antibodies. (Choice E) Patients with gastrinoma (Zollinger-Ellison syndrome) usually have multiple, recurrent ulcers and diarrhea. Fasting serum gastrin levels and secretin stimulation tests are used for diagnosis. However, this patient has a solitary ulcer with a low likelihood of gastrinoma. Educational objective: Patients presenting with peptic ulcer disease and Helicobacter pylori infection from an endemic area should have biopsies of the ulcer to rule out malignancy. Endoscopy may be repeated in 6 weeks after therapy if the biopsies were inadequate or the patient has high risk factors for gastric cancer. __________ References: Gastric cancer carcinogenesis and tumor progression. (http://www.ncbi.nlm.nih.gov/pubmed/22595727) Helicobacter pylori eradication improves gastric atrophy and intestinal metaplasia in long-term observation. (http://www.ncbi.nlm.nih.gov/pubmed/22269293)

A 36-Year-Old Man Comes to the Physician with Daily Epigastric