A 38-year-old woman comes to the office for follow-up after recent hospitalization. The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis. She had intermittent, burning, epigastric pain over the past several months prior to hospitalization. At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy. The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena. She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains. The patient does not use tobacco, alcohol, or illicit drugs and has no allergies. Family history is notable for gastric cancer in her father. Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min. Cardiopulmonary examination is normal. The abdomen is nondistended, soft, and nontender. Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy. The patient returns to the office a month after completing the prescribed treatment. She reports that she initially felt better but has had intermittent recurrence of the abdominal pain. She also has had occasional nausea but no vomiting, hematemesis, hematochezia, or melena. Which of the following is the best next step in management of this patient?

Question

A 38-year-old woman comes to the office for follow-up after recent hospitalization.  The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis.  She had intermittent, burning, epigastric pain over the past several months prior to hospitalization.  At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy.  The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena.  She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains.  The patient does not use tobacco, alcohol, or illicit drugs and has no allergies.  Family history is notable for gastric cancer in her father.  Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min.  Cardiopulmonary examination is normal.  The abdomen is nondistended, soft, and nontender.  Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy. The patient returns to the office a month after completing the prescribed treatment.  She reports that she initially felt better but has had intermittent recurrence of the abdominal pain.  She also has had occasional nausea but no vomiting, hematemesis, hematochezia, or melena.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf48_7562_8f63_cd99967b0e8c_MD0005_00 This patient has persistent symptoms of peptic ulcer disease (PUD), despite completing appropriate treatment, which is concerning for treatment failure. Given increasing antibiotic resistance, Helicobacter pylori eradication should be confirmed for patients with the following: persistent symptoms H pylori-associated ulcer on endoscopy evidence of an H pylori-associated malignancy (eg, mucosa-associated lymphoid tissue lymphoma). Common methods for determining bacterial eradication include urea breath testing and fecal antigen testing. Testing should occur >4 weeks after the completion of therapy. If testing confirms eradication but symptoms remain, other etiologies should also be considered. In patients who do not clear the infection after first-line therapy, second-line options such as quadruple therapy or sequential therapy involving distinct antibiotics should be used. (Choice B) With the advent of effective antibiotic and acid suppression therapy for PUD, surgery is performed mostly for complications such as perforation or refractory hemorrhage. Surgery should not be considered for treatment failure of antibiotic therapy until patients have failed multiple attempts at eradication. (Choice C) Empiric re-treatment without testing for eradication is inappropriate given both the ease of evaluation and the need to consider alternate diagnoses in the setting of persistent symptoms despite elimination of H pylori. (Choice D) Repeat upper endoscopy can help establish whether H pylori has been eradicated; however, given the availability of other less invasive options (eg, urea breath test), it should be reserved for patients with indeterminate indirect testing or with other additional indications for endoscopy. (Choice E) Simply switching to a different proton pump inhibitor is an insufficient strategy given the risk of treatment failure and antibiotic resistance. Educational objective: Patients with persistent symptoms of peptic ulcer disease, evidence of Helicobacter pylori-associated ulcers, or H pylori-associated malignancy should undergo an evaluation to determine bacterial eradication. The preferred options include urea breath testing and fecal antigen testing. References: A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication. (http://www.ncbi.nlm.nih.gov/pubmed/24587620)

A 38-Year-Old Woman Comes to the Office for Follow-Up After