A 39-year-old man comes to the outpatient clinic due to burning epigastric discomfort and nausea for the past 3 months. His symptoms are worse after meals. He has been taking over-the-counter famotidine for the last 2 weeks with no relief of symptoms. The patient has no other medical issues, and family history is unremarkable. He does not use tobacco, alcohol, or illicit drugs. Physical examination shows no abnormalities. Hemoglobin is 15.4 g/dL and serum creatinine is 0.8 mg/dL. Which of the following is the most appropriate next step in management of this patient?
Dyspepsia | |
Symptoms |
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Etiology |
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Work-up |
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Treatment |
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*GI bleeding, weight loss, iron deficiency anemia, lymphadenopathy, dysphagia, odynophagia, persistent vomiting, palpable mass, family history of upper GI cancer. GERD = gastroesophageal reflux disease; GI = gastrointestinal; NSAIDs = nonsteroidal anti-inflammatory drugs. | |
This patient with epigastric/abdominal discomfort and nausea has dyspepsia. Patients may also report a feeling of fullness in the upper abdomen, heartburn, or vomiting; symptoms often worsen postprandially. More than 75% of cases of dyspepsia are functional (idiopathic); however, organic causes include gastritis due to nonsteroidal anti-inflammatory drugs, gastric or esophageal cancer, and symptomatic Helicobacter pylori infection (with or without peptic ulcer).
Management of dyspepsia is dependent on risk of malignancy; patients age ≥60, or younger patients with multiple alarm features (eg, weight loss, iron deficiency anemia, family history of gastrointestinal malignancy), are considered higher risk and should be evaluated with upper endoscopy. However, current guidelines recommend that patients age <60 without alarm features undergo testing for H pylori (ie, stool antigen test, urea breath test). Patients with a positive test should receive a course of appropriate treatment (eg, quadruple therapy), which has been shown to improve dyspepsia symptoms in some patients, as well as reduce the risk of peptic ulcers and gastric malignancy.
(Choices A and E) All patients with newly diagnosed dyspepsia should undergo H pylori testing rather than begin empiric treatment with antisecretory agents, which may mask symptoms or lower the sensitivity of testing. Those with negative results should begin a 4- to 8-week trial of antisecretory therapy, which may help relieve dyspeptic symptoms; however, proton pump inhibitors (PPIs) are more effective than famotidine.
(Choice C) Abdominal ultrasound is an effective imaging modality for biliary disease. Patients with symptomatic gallstones characteristically have intermittent, cramping pain in the right upper quadrant. In atypical cases, the condition may present with epigastric burning, and ultrasound could be considered if evaluation of dyspepsia is not helpful.
(Choice D) Upper gastrointestinal endoscopy is indicated in patients age ≥60 or in younger patients with multiple alarm features. In young patients without alarm features, endoscopy is typically reserved for those with persistent symptoms despite multiple interventions (eg, trial of PPI, tricyclic antidepressant, prokinetic agent).
Educational objective:
Dyspepsia is characterized by epigastric or abdominal discomfort that is often worse after eating; nausea, epigastric fullness, heartburn, or vomiting may also occur. Patients age <60 with dyspepsia who do not have alarm features should undergo Helicobacter pylori testing (eg, stool antigen, urea breath test) with treatment if positive.