A 27-year-old man comes to the office due to episodic abdominal pain. The pain is concentrated in the epigastrium and is gnawing in quality. It wakes him up during the night and is promptly relieved by a glass of water and a piece of bread. The patient has no associated vomiting or diarrhea but has experienced occasional "dark stools." He has no significant past medical history and takes no medications. Family history is significant for biliary disease in his mother. He smokes a pack of cigarettes daily and consumes a can of beer most days. Vital signs are within normal limits. Physical examination shows mild epigastric discomfort on deep palpation. After the diagnosis is confirmed, which of the following is the most appropriate intervention to provide relief of this patient's symptoms?

Question

A 27-year-old man comes to the office due to episodic abdominal pain.  The pain is concentrated in the epigastrium and is gnawing in quality.  It wakes him up during the night and is promptly relieved by a glass of water and a piece of bread.  The patient has no associated vomiting or diarrhea but has experienced occasional "dark stools."  He has no significant past medical history and takes no medications.  Family history is significant for biliary disease in his mother.  He smokes a pack of cigarettes daily and consumes a can of beer most days.  Vital signs are within normal limits.  Physical examination shows mild epigastric discomfort on deep palpation.  After the diagnosis is confirmed, which of the following is the most appropriate intervention to provide relief of this patient's symptoms?

Quizplus · Accepted Answer

Explanation: This patient with epigastric pain and intermittent melena most likely has a duodenal ulcer (DU). The pain of DU is often worse on an empty stomach (possibly due to unopposed gastric acid emptying into the duodenum) and improves with food (due to alkaline fluid secretion into the duodenum). By contrast, the pain of gastric ulcers is often worse after eating (due to increased acid secretion). The majority of DUs are caused by either Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs (NSAIDs). Malignant ulceration should be considered with gastric ulcers but would be very unlikely in this young patient with DU. As this patient has no history of NSAID use, H pylori infection is the most likely etiology and can be confirmed with endoscopic biopsy or urea breath test. Management of DU due to H pylori requires the following: Antisecretory therapy, preferably a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole), and Antibiotic eradication (eg, amoxicillin plus clarithromycin) (Choice A) Compared to antisecretory therapy with antibiotic eradication, antisecretory therapy alone leads to reduced healing rates and a higher risk of recurrent ulcer in patients with H pylori-associated DU. Antisecretory therapy without antibiotics would be recommended for DU attributable to causes other than H pylori. (Choices B and G) Heavy alcohol intake can contribute to hemorrhagic gastritis, but light alcohol intake likely does not affect the course of DU. Smoking appears to increase the risk of peptic ulcer in patients infected with H pylori but does not increase relapse following H pylori eradication. (Choice D) Laparoscopic cholecystectomy is recommended for biliary colic (intermittent, severe right upper quadrant pain with nausea) or acute cholecystitis. This patient's epigastric pain (relieved by food) and melena are unlikely to be due to symptomatic gallbladder disease. (Choice E) NSAIDs can contribute to the risk of DU. Therefore, they are contraindicated during the acute management of DU and should be used with caution following confirmed ulcer resolution. (Choice F) Selective vagotomy decreases gastric acid production by removing vagal input to the stomach. With antibiotic regimens for H pylori and the advent of PPIs, selective vagotomy is used only in refractory cases. Educational objective: Duodenal ulcer (DU) is characterized by epigastric pain that improves with eating. The majority of DUs are caused by Helicobacter pylori or nonsteroidal anti-inflammatory drugs. Management of H pylori-associated ulcer requires acid suppression and antibiotic eradication therapy. References: Helicobacter pylori and gastric or duodenal ulcer. (http://www.ncbi.nlm.nih.gov/pubmed/26942258) A prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men. (http://www.ncbi.nlm.nih.gov/pubmed/9209857) Does smoking predispose to peptic ulcer relapse after eradication of Helicobacter pylori? (http://www.ncbi.nlm.nih.gov/pubmed/9068465)

A 27-Year-Old Man Comes to the Office Due to Episodic