A 69-year-old man is evaluated for abdominal pain. Upper gastrointestinal endoscopy shows a single shallow, 1-cm ulcer in the duodenal bulb and mild gastric erythema. Biopsy specimens from the gastric antrum do not show Helicobacter pylori, and stool testing for H pylori antigen is negative. Which of the following parts of the history is most likely to reveal the cause of this patient's current condition?

Question

A 69-year-old man is evaluated for abdominal pain.  Upper gastrointestinal endoscopy shows a single shallow, 1-cm ulcer in the duodenal bulb and mild gastric erythema.  Biopsy specimens from the gastric antrum do not show Helicobacter pylori, and stool testing for H pylori antigen is negative.  Which of the following parts of the history is most likely to reveal the cause of this patient's current condition?

Quizplus · Accepted Answer

11ec160b_395b_c6b9_9249_81bea8b53db3_MD0001_00 Peptic ulcers (defects in the stomach or duodenal mucosa) are most commonly due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use. The majority of duodenal ulcers are associated with H pylori infection, but the prevalence is decreasing in the United States due to improved hygienic practices. H pylori has been adequately ruled out in this patient; therefore, he most likely has an NSAID-related duodenal ulcer. Nonselective NSAIDs (eg, ibuprofen, naproxen, aspirin) exert analgesic, anti-inflammatory, and antipyretic effects through the inhibition of both forms of the cyclo-oxygenase (COX) enzyme. In the gastrointestinal tract, the COX-1 subtype is responsible for the synthesis of prostaglandins, which are critical for the maintenance of intestinal mucosa. Inhibition of COX-1 leads to increased gastric acid formation, decreased mucosal bicarbonate production, and decreased mucosal blood flow, which can increase the risk for gastritis and peptic ulcer formation. Patients who are age >65 or those on long-term or high-dose NSAID therapy are at the highest risk. (Choice A) Multiple endocrine neoplasia type 1 is a rare hereditary disorder that presents with pituitary, parathyroid, and pancreatic tumors, including gastrinomas. Gastrinomas manifest as peptic ulcer disease, but patients typically develop multiple ulcers and often have evidence of other neoplasias (eg, hypercalcemia from hyperparathyroidism, visual field defects from pituitary adenomas). (Choices B and E) Diet and seasonal allergies are not associated with peptic ulcer disease, although certain foods (eg, spicy) may exacerbate ulcer-related dyspepsia and abdominal pain. (Choice D) Travel to a resource-limited country increases the risk of H pylori infection; however, H pylori was ruled out in this patient. Educational objective: Peptic ulcers are most commonly caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use. NSAIDs inhibit cyclo-oxygenase-1, leading to increased gastric acid formation, decreased mucosal bicarbonate production, and decreased mucosal blood flow, which promote mucosal injury and ulcer formation.

A 69-Year-Old Man Is Evaluated for Abdominal Pain