A 42-year-old woman comes to the office due to 4 weeks of episodic upper abdominal pain. The patient describes a burning pain that waxes and wanes and is associated with nausea. On several occasions, the pain has awakened her at night, and she has a bloating sensation after meals. The patient has had no dysphagia, regurgitation, weight loss, or change in bowel habits. She emigrated from India 20 years ago and works as a patient care assistant. The patient takes no medications and does not use tobacco or alcohol. She has no family history of gastrointestinal cancer. Vital signs are normal. BMI is 28 kg/m². The abdomen is soft and nontender with normal bowel sounds and no masses or organomegaly. Stool guaiac is positive. Which of the following is the most likely underlying cause of this patient's symptoms?

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11ec25c8_d3e6_fcd5_bc81_87270d45238b_MD0003_00 This patient has dyspepsia (ie, burning intermittent epigastric pain and postprandial discomfort), postprandial bloating, and nausea associated with a positive stool guaiac. In association with her younger age (<65), absence of features concerning for malignancy (ie, dysphagia, regurgitation, weight loss, change in bowel habits), and history of living in an area with a high prevalence of infection (eg, parts of Asia), this presentation suggests Helicobacter pylori infection complicated by peptic ulcer disease. H pylori is a urease-producing organism that commonly causes dyspeptic symptoms. It colonizes the stomach and induces excessive production of gastric acid by the parietal cells, which can eventually lead to duodenal ulcer formation. Other common symptoms of duodenal ulcers include nocturnal pain (due to circadian rhythm of gastric acid secretion), worsening of the pain with fasting, postprandial bloating, and nausea. Biopsy of the gastric antrum during endoscopy can confirm infection. In a patient without occult bleeding, noninvasive diagnostic testing, including stool antigen studies and urea breath testing, can be employed. Serology cannot distinguish between active and cleared infection and is not preferred. (Choice A) Biliary cholesterol supersaturation is involved in cholesterol gallstone formation. Gallstones usually cause right upper quadrant pain, nausea, and diaphoresis. A positive stool guaiac is unexpected. (Choice B) Although gastrin-secreting pancreatic tumors (eg, Zollinger-Ellison syndrome) can result in dyspepsia and duodenal ulcers, they are very rare and usually accompanied by chronic diarrhea and weight loss. This patient's history and normal bowel habits make H pylori infection more likely. (Choice C) Primary biliary cholangitis, which occurs due to immune-mediated bile duct destruction, most frequently presents with chronic fatigue, pruritus, and jaundice. (Choice D) Celiac disease leads to immune-mediated destruction of the intestinal villi. It can be asymptomatic or cause severe diarrhea, flatulence, or iron deficiency anemia; dyspepsia is uncommon. (Choice E) Although both achalasia and gastroesophageal reflux disease (GERD) result from lower esophageal sphincter dysfunction and may cause dyspepsia, bleeding is not typical. In addition, achalasia typically presents with weight loss, dysphagia for solid foods, and regurgitation of undigested food. GERD presents with heartburn (retrosternal burning pain) and much milder regurgitation. Educational objective: Helicobacter pylori is a urease-producing organism that can cause peptic ulcer disease. Symptoms of peptic ulcers include dyspepsia, postprandial fullness and nausea, and gastrointestinal bleeding; worsening pain during fasting and nocturnal pain can also occur.

A 42-Year-Old Woman Comes to the Office Due to 4