A 34-year-old man is evaluated for several months of epigastric pain that is worse at night and is relieved by eating. The patient has no significant medical history and takes no medications. He does not use tobacco, alcohol, or illicit drugs. The patient immigrated to the United States from China 4 years ago. Vital signs are within normal limits. Physical examination shows mild epigastric tenderness to deep palpation. Upper gastrointestinal endoscopy reveals a 1-cm ulcer in the first portion of the duodenum. Additional testing is pending. In addition to proton pump inhibitor therapy, which of the following therapies would most likely prevent ulcer recurrence in this patient?

Question

A 34-year-old man is evaluated for several months of epigastric pain that is worse at night and is relieved by eating.  The patient has no significant medical history and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  The patient immigrated to the United States from China 4 years ago.  Vital signs are within normal limits.  Physical examination shows mild epigastric tenderness to deep palpation.  Upper gastrointestinal endoscopy reveals a 1-cm ulcer in the first portion of the duodenum.  Additional testing is pending.  In addition to proton pump inhibitor therapy, which of the following therapies would most likely prevent ulcer recurrence in this patient?

Quizplus · Accepted Answer

11ec160b_3bd5_521f_9249_b79210d292a2_MD0001_00 This patient's symptoms and endoscopic findings are consistent with duodenal peptic ulcer disease (PUD). Up to 90% of duodenal ulcers are caused by Helicobacter pylori infection. The remaining cases are typically associated with nonsteroidal anti-inflammatory drug (NSAID) use, which is unlikely in this patient who takes no medications. Over 50% of the world population is colonized with H pylori, with a particularly high prevalence in resource-limited countries, including much of Africa, Western Asia, and South America. To reduce the likelihood of PUD recurrence after ulcer healing, H pylori infection must be eradicated. Effective regimens typically involve a combination of antibiotics (eg, tetracycline, metronidazole) and proton pump inhibitors (eg, omeprazole), often with bismuth subsalicylate (ie, quadruple therapy). The antibiotic regimen can be tailored based on local resistance patterns. (Choice B) Gastric cytoprotectants (eg, sucralfate) bind to the base of mucosal ulcers and protect them against gastric acid. This can help duodenal ulcers heal but would be less effective in preventing ulcer recurrence than eradication of H pylori. (Choice C) Glucocorticoids should be avoided in patients with PUD as they can promote peptic ulcer formation, especially when combined with NSAIDs. (Choice D) Proton pump inhibitors suppress gastric acid secretion to a greater extent than histamine H2-receptor blockers (eg, ranitidine), allowing for superior ulcer healing during PUD treatment. However, neither medication would prevent ulcer recurrence (which requires H pylori eradication). (Choice E) Metoclopramide is a dopamine antagonist with prokinetic and antiemetic properties that can be used to treat gastrointestinal motility disorders (eg, gastroparesis) and nausea/vomiting; however, it does not have a significant effect on PUD. (Choice F) Prostaglandin analogues such as misoprostol are used to prevent NSAID-induced peptic ulcers. Educational objective: Most duodenal peptic ulcers are caused by Helicobacter pylori infection. The most effective method to prevent disease recurrence is to eradicate the infection with antibiotics (eg, tetracycline, metronidazole), typically in combination with proton pump inhibitors (eg, omeprazole) and, often, bismuth subsalicylate (quadruple therapy). __________ References: A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication. (http://www.ncbi.nlm.nih.gov/pubmed/24587620)

A 34-Year-Old Man Is Evaluated for Several Months of Epigastric