A 72-year-old man comes to the office due to upper abdominal pain and weight loss. The abdominal pain is worse when eating food and is sometimes relieved with over-the-counter antacids. He has not had dysphagia, melena, or rectal bleeding. The patient has a history of hypertension, which is well controlled with chlorthalidone. He does not take other prescription or over-the-counter medications and does not use tobacco, alcohol, or illicit drugs. The patient emigrated from South Korea 20 years ago. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 14/min. BMI is 17.2 kg/m². Mucous membranes are dry. Cardiopulmonary examination shows no abnormalities. Epigastric fullness and tenderness are present, but there is no hepatosplenomegaly. Peripheral pulses are full and capillary refill is normal. Which of the following is the best next step in management?

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This patient's weight loss, epigastric fullness, and abdominal pain relieved with antacids raise suspicion for gastric cancer. Incidence is particularly high in Eastern Asia (eg, South Korea), Eastern Europe, and the Andean part of South America where diets are rich in salt-preserved foods (damages stomach mucosa) and nitroso compounds (carcinogenic). Other risk factors include Helicobacter pylori infection, smoking, alcohol use, and atrophic gastritis. Patients with gastric cancer usually develop persistent epigastric pain that often worsens with eating (due to the irritant effects of gastric acid on the tumor) and weight loss (due to insufficient caloric intake). Proximal stomach tumors may also cause dysphagia and postprandial nausea and vomiting. The diagnosis is generally established using esophagogastroduodenoscopy (EGD) to visualize the stomach and obtain biopsy samples of suspicious lesions. (Choice A) Although carcinoembryonic antigen (CEA) may be elevated in some cases of gastric cancer, this test has low sensitivity and cannot be used to rule out or screen for a gastric tumor. CEA is used for follow-up (not screening or diagnosis) of colorectal cancer, which is unlikely to cause upper abdominal pain and is associated with rectal bleeding. (Choice B) CT angiogram of the mesenteric vessels can diagnose mesenteric ischemia, which often causes severe abdominal pain following eating (ie, "intestinal angina"). However, relief with antacids would be atypical, and most patients have risk factors (eg, smoking, hyperlipidemia, diabetes mellitus) for atherosclerotic disease. (Choice C) Abdominal CT scan is often normal in early gastric cancer, so it is not used for initial evaluation. However, abdominal CT scan may be performed later to evaluate for distant metastases (eg, liver). (Choice E) A gastric emptying scan can diagnose gastroparesis, which is most common in patients with uncontrolled diabetes mellitus. Most cases are marked by nausea, vomiting, abdominal pain, and bloating following eating. (Choice F) H pylori is a major risk factor for gastritis, gastric ulcer, and gastric cancer. However, EGD is required prior to H pylori stool testing to establish the underlying stomach pathology. Educational objective: Gastric cancer is endemic to Eastern Asia, Eastern Europe, and the Andean portions of South America due to diets high in salt-preserved food and nitroso compounds. Manifestations typically include weight loss and chronic mid-epigastric pain that worsens with eating. Esophagogastroduodenoscopy is the initial test of choice to establish the diagnosis. References: Screening of gastric cancer: who, when, and how (http://www.ncbi.nlm.nih.gov/pubmed/24107396) Effective reduction of gastric cancer risk with regular use of nonsteroidal anti-inflammatory drugs in Helicobacter pylori-infected patients. (http://www.ncbi.nlm.nih.gov/pubmed/20479409) Chronic mesenteric ischemia: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/21326544)

A 72-Year-Old Man Comes to the Office Due to Upper