A 67-year-old woman comes to the office due to 4 weeks of upper abdominal pain. She also has epigastric fullness and mild nausea that occur mostly after eating and sometimes at night. The patient has had no vomiting, weight loss, dysphagia, acid reflux, or black or bloody stools. Medical history includes hypertension, hyperlipidemia, migraines, and mild intermittent asthma. Medications include lisinopril and atorvastatin. The patient's father died of colon cancer at age 75. On physical examination, the abdomen is soft and nontender. There is no jaundice or palpable masses. Hemoglobin is 13.2 g/dL. Colonoscopy 3 years ago was normal. Which of the following is the best next step in management of this patient?

Question

A 67-year-old woman comes to the office due to 4 weeks of upper abdominal pain.  She also has epigastric fullness and mild nausea that occur mostly after eating and sometimes at night.  The patient has had no vomiting, weight loss, dysphagia, acid reflux, or black or bloody stools.  Medical history includes hypertension, hyperlipidemia, migraines, and mild intermittent asthma.  Medications include lisinopril and atorvastatin.  The patient's father died of colon cancer at age 75.  On physical examination, the abdomen is soft and nontender.  There is no jaundice or palpable masses.  Hemoglobin is 13.2 g/dL.  Colonoscopy 3 years ago was normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf2e_f9cc_8f63_3de3cc98701c_MD0005_00 This patient with abdominal pain, epigastric fullness, and nausea that worsen after eating has dyspepsia. Most cases of dyspepsia are functional (idiopathic), but nearly 25% have an organic cause such as peptic ulcer disease, gastroesophageal reflux disease, gastroesophageal malignancy, or NSAID-induced gastritis. Management of dyspepsia is dependent on the risk of malignancy. Patients age ≥60 are considered high risk and should undergo upper gastrointestinal endoscopy with biopsy. Endoscopy is also indicated in patients age <60 with significant weight loss, overt gastrointestinal bleeding, or >1 alarm feature (persistent vomiting, progressive dysphagia or odynophagia, palpable mass or lymphadenopathy, unexplained iron deficiency anemia, family history of gastrointestinal malignancy). (Choice A) Barium swallow is useful in evaluating patients for motility disorders (eg, diffuse esophageal spasm) or structural esophageal disease (eg, esophageal stricture). However, these patients typically develop predominant dysphagia rather than significant dyspepsia. (Choices B and C) Patients with dyspepsia who are age <60 and do not have alarm signs should be tested for Helicobacter pylori infection (eg, stool antigen, urea breath test) and treated if positive. Those who are negative for H pylori or fail to respond to therapy can be treated empirically with a proton pump inhibitor (eg, pantoprazole, omeprazole). However, due to her age, this patient should undergo upper endoscopy to rule out malignancy. (Choice D) Ultrasound of the right upper quadrant is usually indicated for patients with symptoms of biliary disease (eg, postprandial pain in the right upper quadrant, nausea, diaphoresis) rather than dyspepsia. Educational objective: Dyspepsia is characterized by epigastric pain that is often associated with postprandial fullness and/or nausea. Patients age ≥60 with new dyspepsia should undergo upper endoscopy to rule out malignancy. Endoscopy is also recommended for patients age <60 with significant weight loss, overt gastrointestinal bleeding, or >1 alarm feature (persistent vomiting, progressive dysphagia or odynophagia, palpable mass or lymphadenopathy, unexplained iron deficiency anemia, family history of gastrointestinal malignancy). References: ACG and CAG clinical guideline: management of dyspepsia. (http://www.ncbi.nlm.nih.gov/pubmed/28631728)

A 67-Year-Old Woman Comes to the Office Due to 4