A 31-year-old man comes to the office due to fullness in the epigastric area and occasional nausea over several months. He has had no heartburn, dysphagia, early satiety, or weight loss. The patient has no other medical conditions and takes no medications, including over-the-counter supplements. He does not use tobacco, alcohol, or illicit drugs. Family history is not significant, and the patient has no known drug allergies. Vital signs are within normal limits. Examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient?

Question

A 31-year-old man comes to the office due to fullness in the epigastric area and occasional nausea over several months.  He has had no heartburn, dysphagia, early satiety, or weight loss.  The patient has no other medical conditions and takes no medications, including over-the-counter supplements.  He does not use tobacco, alcohol, or illicit drugs.  Family history is not significant, and the patient has no known drug allergies.  Vital signs are within normal limits.  Examination shows no abnormalities.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf2e_849b_8f63_7551e0c35e8e_MD0005_00 This young patient with epigastric fullness and nausea has dyspepsia. Although most cases are idiopathic (functional), dyspepsia can occur in patients with gastroesophageal malignancy, peptic ulcer disease, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection. Management of dyspepsia is dependent on the age of the patient and the presence of alarm symptoms. In patients age ≥60 with dyspepsia, endoscopy is indicated to rule out possible gastroesophageal malignancy because of the high risk in this age group. In patients age <60, the risk of malignancy is lower; therefore, endoscopy is only required among those with alarm symptoms (eg, dysphagia, weight loss) (Choice E). Individuals age <60 without alarm features, such as this patient, should undergo H pylori testing (eg, stool antigen, urea breath testing), with multidrug eradication therapy if positive (ie, test-and-treat method). In addition to reducing the risk for peptic ulcer disease and gastric malignancy, eradication of H pylori has been shown to improve dyspeptic symptoms in some patients. (Choice A) CT scan of the abdomen and pelvis is indicated in patients with possible malignancy. This patient has no alarm symptoms, so he does not require imaging. (Choice B) Current guidelines do not recommend dietary modifications for dyspepsia because they are generally ineffective. Dietary modifications are more effective for gastroesophageal reflux disease (eg, retrosternal burning, reflux of acidic gastric contents into the mouth). (Choice D) A trial of a proton pump inhibitor is indicated for patients who test negative for H pylori. However, these medications should not be administered prior to the test because they may reduce its sensitivity. Educational objective: Dyspepsia is characterized by epigastric discomfort or fullness and is often associated with nausea. A test-and-treat method for Helicobacter pylori infection is recommended in patients age <60 without alarm symptoms. Patients age ≥60 or those with alarm symptoms should undergo endoscopy to rule out malignancy.

A 31-Year-Old Man Comes to the Office Due to Fullness