Clinical Pearls

The acute onset of painless jaundice in a patient older than age 50 years should prompt an examination for pancreatic cancer (malignancy in the head of the pancreas causing compression of the bile ducts).

All pregnant women should be screened for the presence of HBsAg. If positive, treating the newborns with hepatitis B immunoglobulin (HBIg) and vaccination can reduce the risk of vertical transmission.

One of the greatest risks for the development of cirrhosis in those with chronic hepatitis C is alcohol use. Anyone with chronic hepatitis C should be counseled to avoid all alcohol intake.

REFERENCES

Centers for Disease Control and Prevention. Diagnosis and management of food-

borne illnesses. MMWR 2004:53(RR04):t-33. National Institutes of Health. Management of hepatitis C: 2002. Consensus statement.

Available at: http://consensus.nih.gov/2002/2002hepatitisC2002116html.htm. Roche SP. Kobos R. Jaundice in the adult patient. Am Fam Physician 2004:69: 299-304.

Workowski KA, Levine WC. Sexually transmitted diseases treatment guidelines, 2002. MMWR 2002:5KRR06): 1-80.

A 52-year-old man presents to the office with approximately 2 weeks of upper abdominal pain. His symptoms are difficult for him to describe, but include some "discomfort" in the epigastric region that comes and goes. He has had some "heartburn" and nausea, but no vomiting or diarrhea. He has noticed that his stool looks darker than it used to, but he has not seen any blood. He feels full quickly after eating. He tried taking some over-the-counter antacid, which helps a little, but not much. His only other medication is an over-the-counter nonsteroidal antiinflammatory drug (NSAID) that he takes "once or twice" a day because of arthritis in his knees. He does not smoke cigarettes or drink alcohol. On examination, he is pale appearing, but in no acute discomfort. He is afebrile, his blood pressure is 120/80 mm Hg, his pulse is 95 beats/min. and his respiratory rate is 14 breaths/min. Head. ears, eyes, nose, and throat (HEENT) examination is notable only for pale conjunctiva. Cardiac and pulmonary examinations are normal. His abdomen has normoactive bowel sounds and tenderness in the epigastrium. There is no mass, rebound, or guarding. Rectal examination reveals normal tone, no masses, and dark black stool that is strongly heme positive. The remainder of his examination is unremarkable.

^ What is the most likely diagnosis?

♦ What evaluation and treatment is indicated at this point? ^ What can be done to reduce the risk of recurrence of this problem?

ANSWERS TO CASE 47: Peptic Ulcer Disease

Summary: A 52-year-old male presents with vague upper abdominal discomfort, nausea and early satiety. He is a daily NSAID user. He appears pale on examination, suggesting that he may be anemic. He has mild abdominal tenderness and melanotic stool on examination.

♦ Most likely diagnosis: Bleeding peptic ulcer

♦ Evaluation and treatment at this point: A stat complete blood count (CBC), discontinuation of his NSAID. upper Gl endoscopy, and testing for Helicobacter pylori. He should be treated with a proton pump inhibitor (PPI) and antibiotics for H. pylori, if tests confirm its presence. He may need a blood transfusion (dependent on the result of his CBC). He will also require evaluation with a colonoscopy.

♦ Reduce risk of recurrence by: Discontinuation and avoidance of NSAID or, if unable to completely discontinue, use of PPI with the NSAID; eradication of H. pylori.

Analysis

Objectives

1. Learn the risk factors for the development of peptic ulcer disease (PUD).

2. Know how to diagnose and treat peptic ulcers.

3. Understand the role of H. pylori in PUD, including methods for testing for and treatment of PUD.

4. Know the "alarm symptoms" for which endoscopy is indicated.

Considerations

Dyspepsia is defined as chronic or recurrent upper abdominal pain or discomfort. Approximately 10% of dyspepsia is caused by peptic ulcer disease. Other common causes include gastroesophageal reflux disease (GERD) and functional dyspepsia. The diagnostic work-up and treatment of patients with dyspepsia varies and is dependent on the age of the patient, the presenting symptoms and signs, and the response to the initial management offered.

Early diagnostic endoscopy should be considered for patients with new-onset dyspepsia who are older than age 55 years or who have symptoms that may be associated with upper GI malignancy (Table 47-1). For those younger than age 55 years and without alarm symptoms, testing for H. pylori. either by urea breath test or stool antigen testing, is recommended. For those who test positive, treating the H. pylori followed by acid-suppression therapy is indicated. For persons who test negative, empiric therapy with a PPI for 4—8 weeks

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