Nursing Discussion

Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and she suggests that you see Mr. Cesar Rodriguez, a 39-year-old uninsured male who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez's first visit to the clinic.

Molly, Dr. Medel's medical assistant, has already escorted Mr. Rodriguez to the examination room and has arranged for a Spanish-speaking interpreter to be present for the visit, since he speaks and comprehends very little English. Molly tells you that Mr. Rodriguez has been having "worsening abdominal pain over the past several months" and is "worried that something is wrong."

Dr. Medel says to you, "How would you begin to think about what might be going on with Mr. Rodriguez?"

You reply, "Abdominal pain can be caused by a wide variety of conditions. I'll need to get more information about his symptoms to form an appropriate differential diagnosis. At this point I'd have to consider several organ systems as potential etiologies of the pain."

"Very good," Dr. Medel responds. "Why don't you go ahead and talk with Mr. Rodriguez and come find me afterward. Lola, our Spanish-speaking interpreter, can help."

TEACHING POINT

Systems Approach to Abdominal Pain

Gastrointestinal	Appendicitis, cholecystitis/cholelithiasis, diverticulitis/diverticulosis, dyspepsia, gastroesophageal reflux disease, gastritis, acute or chronic hepatic failure with resulting complications (e.g., ascites), acute hepatitis (e.g., viral, autoimmune, alcoholic, drug-induced), inflammatory bowel disease, intestinal ischemia, intestinal obstruction, irritable bowel syndrome, pancreatitis, peptic ulcer, perforation/peritonitis (e.g., gastric, colonic, intestinal), gastric outlet obstruction, tumor (e.g., gastric, hepatic, pancreatic, intestinal, colonic).
Cardiac	Myocardial infarction, angina pectoris, abdominal aortic aneurysm dissection or rupture.
Psychogenic	Anxiety, panic disorder, somatoform disorder, post-traumatic stress disorder.
Pulmonary	Pleurisy, lower lobe pneumonia, pulmonary infarction, tumor.
Renal	Nephrolithiasis, pyelonephritis, cystitis, tumor.
Musculoskeletal	Abdominal wall muscle strain, hernia (e.g., ventral, inguinal, incarcerated), abscess (e.g., psoas, subphrenic), trauma (e.g., contusion, hematoma), cutaneous nerve entrapment.
Metabolic	Drug overdose, ketoacidosis, iron or lead poisoning, uremia, acute intermittent porphyria.

Also consider:

· Medication, vitamin, and herbal supplement side effects

· Dietary factors (dietary intolerances, such as lactose, gluten, fructose, or artificial sweeteners [e.g., sorbitol, xylitol, sucralose])

TEACHING POINT

How to Interview a Patient Via an Interpreter

· Speak as you would normally, directly to the patient and not to the interpreter.

· The interpreter should interpret in the first person, without editing it in any way.

· Often, the interpreter will sit just behind the patient and in their ear, or off to the side where the interpreter won't obstruct your ability to face the patient, make direct eye contact, and feel like you're talking with the patient directly.

· Ideally, it should feel like the interpreter is just a conduit for the conversation between you and the patient.

As you walk down the hall, Lola, the Spanish-speaking interpreter, gives you some tips on how to interview a patient with an interpreter.

You and Lola enter the room. You sit directly across from Mr. Rodriguez, with Lola sitting just off to your left and facing him. You sense that Mr. Rodriguez seems anxious about coming to the physician today. You introduce yourself and ask,

"What brings you in today?"

"Is there anything that makes the pain better or worse?"

"What worries you the most about your symptoms?"

Thinking about some of the common causes of abdominal pain, you conduct a focused review of systems:

· General: Reports no weight loss, fevers, chills, or night sweats. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.

· GI: Reports no dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation.

· GU: Reports no dysuria, hematuria, or change in frequency.

· CVS/Respiratory: Reports no chest pain, cough, or shortness of breath.

MEDICAL AND FAMILY HISTORY

HISTORY

You now direct your attention to Mr. Rodriguez' medical history.

"Do you have any chronic medical problems?"

"Have you ever been hospitalized or had any surgeries?"

"Do you take any medicines or supplements?"

"Does anyone in your family have any medical conditions—for example, heart or blood pressure problems? Diabetes?"

"Does anyone in your family have stomach problems or pain similar to yours?"

You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily but quit six months ago. He drinks three to four beers per week. He reports no other drug use. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.

You congratulate Mr. Rodriguez on quitting smoking and you thank him for answering all of your questions. You review in your mind what you've learned from Mr. Rodriguez so far, and find yourself still wondering about why he seems a little anxious. Before you go to get Dr. Medel, you inquire,

"It seems like this has really been bothering you. Is there anything else we haven't talked about that seems important?"

ACCESS TO CARE

TEACHING

You reply, "Well, I'm glad you came in today, and I'll be sure and share your concern with Dr. Medel. Thanks for telling me."

You ask him to change into a gown, taking off his clothes. You reassure him that you will return with Dr. Medel momentarily, and you and Lola leave the exam room while Mr. Rodriguez changes.

In the hallway, you comment to Lola that you are concerned about why Mr. Rodriguez waited to come see a doctor.

DIFFERENTIAL DIAGNOSIS

CLINICAL REASONING

Dr. Medel praises your summary and then asks you to commit to a provisional differential diagnosis for Mr. Rodriguez's abdominal pain, based on your findings from his history.

Question

From the following, select the top three diagnoses on your differential.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Abdominal wall muscle strain

· B. Acute Pancreatitis

· C. Angina pectoris

· D. Anxiety

· E. Diverticulitis

· F. Gastritis

· G. Gastroesophageal reflux disease (GERD)

· H. Peptic ulcer disease (PUD)

· I. Pneumonia

SUBMIT

Answer Comment

The correct answers are F, G, H.

TEACHING POINT

Differential for Chronic Progressively Worsening Upper Abdominal Pain

Most Likely / Most Important Diagnoses

Gastritis	· Inflammation or irritation of the stomach lining often causing sharp epigastric pain. This pain may be variably worsened or improved with eating food. · Inflammatory forms of gastritis may be caused by chronic infections, such as  H. pylori, or acute infections, such as enterovirus. · Noninflammatory forms of "gastritis" are histologically termed gastropathy. These may be caused by chemical irritants to the stomach, including alcohol and medications.
GERD	· May present with mild epigastric pain and symptoms commonly worsen after meals, although the pain is classically described as "burning" and is typically located in the substernalrather than epigastric area. · May be associated with regurgitation and, rarely, dysphagia. · Hematemesis in the setting of GERD-like symptoms is unusual and represents an alarm symptom indicative of an upper GI bleed warranting prompt GI referral for evaluation and upper endoscopy. · Nausea, vomiting, hematochezia, and melena are not typically associated with GERD.
Peptic ulcer disease (PUD)	· Epigastric abdominal pain that improves with meals is the hallmark of PUD. However, in some cases, symptoms of PUD may worsen with meals. · NSAID use is associated with the development of PUD. · Hematemesis, if present, suggests more complicated disease, such as bleeding ulcer, and warrants urgent GI referral and endoscopy.  · Melena commonly occurs in the setting of an upper GI bleed secondary to PUD or hemorrhagic gastritis (e.g., NSAID-gastritis). Hematochezia only occurs in the setting of an upper GI bleed when massive (e.g., variceal rupture).

Less Likely Diagnoses

Abdominal wall muscle strain	· Unlikely in the absence of a positional component to the pain.
Acute pancreatitis	· Causes severe abdominal pain, associated with nausea and vomiting, ill appearance on exam, and clinical signs of dehydration such as tachycardia. · Pain is typically located in the epigastric area with radiation to the back, improves with leaning forward, and worsens with eating. Symptoms often last for many hours without relief. · Leads to elevations in serum lipase and amylase. · Acute and chronic pancreatitis are most commonly caused by alcohol useand gallstones. Remember that some patients may not be forthcoming about their actual alcohol use, especially if they perceive they are being judged or if they are in denial about problem use/abuse.
Angina pectoris	· Classically presents with substernal chest pain, but may present with epigastric abdominal pain and nausea or vomiting. · Interestingly, GERD is the most common cause of noncardiac chest pain (NCCP).
Anxiety	· A possible etiology for abdominal pain, but other diagnoses should always be considered first. · Can be associated with additional types of body pain, and patients who have anxiety disorders may self-medicate (i.e., with alcohol), which may warrant further careful exploration.
Diverticulitis	· Classically presents with acute left lower quadrant abdominal pain, change in bowel movements, and fever. · Most common in patients over 50 years of age.
Pneumonia	· Unlikely in the absence of pulmonary symptoms and fever.

The absence of hematemesis, hematochezia, or melena is reassuring that significant GI bleeding is unlikely to be present, but does not help to distinguish between these three diagnoses, all of which commonly present without GI bleeding.

DYSPEPSIA DEFINED

After careful consideration, you tell Dr. Medel that you are concerned that Mr. Rodriguez has either gastritis, gastroesophageal reflux disease (GERD), or peptic ulcer disease (PUD). You and Dr. Medel discuss the various causes of dyspepsia.

You tell Dr. Medel you are confused as to how to differentiate the etiologies of dyspepsia. Dr. Medel replies, "That is understandable, as this is like piecing together a puzzle. There is no one right answer for every patient. Instead, you have to consider the clinical picture as a whole. We'll need to consider each possible etiology for dyspepsia for Mr. Rodriguez."

TEACHING POINT

Dyspepsia: Definition, Symptoms, Epidemiology, and Etiology

Definition

Dyspepsia is literally "bad digestion." Patients commonly describe having "indigestion."

Symptoms

Patients with this condition experience upper abdominal pain or discomfort that is episodic or persistent. It is often associated with belching, bloating, heartburn, early satiety, nausea, and/or vomiting.

Epidemiology

About a quarter of adults are affected by dyspepsia, but many people self-diagnose and self-treat. Even though most people don't seek medical care for it, dyspepsia accounts for approximately 5% of all visits to family physicians and is the most common symptom leading to GI referral in the U.S.

Etiology

Condition	% of Dyspepsia Cases
Functional or non-ulcer dyspepsia (specific etiology for dyspepsia can't be identified)	~ 50%
Peptic ulcer disease (PUD)	20%
GERD	20%
Gastritis / duodenitis	10%
Medication side effects	Common
Pancreatitis	Less common
Gastric, pancreatic, and esophageal cancer	Important though uncommon (< 2%)
Non-GI causes (such as angina and dissecting aortic aneurysm)	Rare, but should always be included in ddx

CAUSES OF DYSPEPSIA

You tell Dr. Medel that you are still unsure how to differentiate between dyspepsia due to gastroesophageal reflux disease (GERD) and dyspepsia due to peptic ulcer disease (PUD).

Question

Which of the following are TRUE regarding dyspepsia due to GERD or PUD? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. GERD can be distinguished from other gastrointestinal disorders with reasonable accuracy on the basis of symptoms.

· B. Eating and drinking make GERD symptoms improve and PUD symptoms worse.

· C. Peptic ulcers may be associated with nausea and vomiting that can occur anytime shortly after eating up to several hours later.

· D. Non-erosive reflux disease (NERD) is the most common form of GERD.

· E. Patients with GERD report lower health-related quality of life than patients with heart failure.

SUBMIT

Answer Comment

The correct answers are A, C, D, E.

The symptoms that patients describe often overlap and can make it tricky to determine the etiology of dyspepsia. However, some symptoms can help distinguish GERD from other gastrointestinal disorders with reasonable accuracy.

TEACHING POINT

Peptic Ulcer Disease Versus Gastroesophageal Reflux Disease Symptoms

Some symptoms of PUD directly contrast those of GERD.

PUD	GERD
Characterized by episodic or recurrent epigastric "aching," "gnawing," or "hunger-like" pain or discomfort	Classic symptoms of retrosternal heartburn and regurgitation
Symptoms occur on an empty stomach and are commonly relieved by meals	More likely to occur when gastric volume is increased (after large meals)

However, this is not always true, and there can be some differences in symptoms based on the location of an ulcer.

For example, gastric ulcer pain may occur 5 to 15 minutes after eating and remain until the stomach empties, which may be up to several hours in duration; the pain may otherwise be absent during times of fasting. Pain from duodenal ulcers is often relieved by eating, drinking milk, or taking antacids but may return anywhere from 90 minutes to four hours after eating a meal. Both gastric and duodenal ulcers may be associated with nausea and vomiting occurring anytime shortly after eating to several hours later.

Given the population prevalence of obesity and hiatal hernia, conditions that predispose a patient to GERD, it is not uncommon for a patient with PUD to also have GERD.

TEACHING POINT

Gastroesophageal Reflux Disease: Pathophysiology, Symptoms, Complications, and Quality of Life

Pathophysiology

GERD is a chronic relapsing condition in which gastric contents reflux through the lower esophageal sphincter (LES) into the esophagus and oropharynx. Transient LES relaxations are believed to be the primary etiologic factor. Ineffective esophageal clearance (as seen with scleroderma, for example) and delayed gastric emptying (as seen with gastroparesis, for example) may also be contributing factors in some patients. Increased intra-abdominal pressure is also a predisposing factor (obesity/central adiposity, pregnancy, constricting garments), especially in the presence of hiatal hernia.

Symptoms

1. Gastroesophageal reflux: epigastric burning that sometimes radiates to the throat and tends to worsen when:

· gastric volume is increased (after large meals)

· gastric contents are located near the gastroesophageal junction (reclining or bending)

· intra-abdominal pressure is increased (such as with obesity, pregnancy, abdominal binders, or girdles).

2. Esophageal spasm: sharp, stabbing, substernal pain that can be triggered by temperature extremes (e.g., hot coffee, ice water).

Heartburn, esophageal reflux, and esophageal spasm commonly occur at night or after the consumption of trigger foods or a large meal.

Symptoms of GERD may also be precipitated by:

· Spicy, acidic, and fatty foods

· Chocolate

· Mint

· Smoking

· Alcohol and caffeine

· Eating large portions

· Lying flat after a meal

· Wearing tight clothing around the waist

· Some medications (calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives)

When severe reflux reaches the pharynx and mouth or is aspirated, it can cause atypical signs and symptoms of GERD or laryngopharyngeal reflux (LPR). Atypical symptoms may point to (but don't sufficiently support by themselves) a diagnosis of GERD.

Atypical signs and symptoms of GERD:

· Asthma, especially new onset in an adult with no history of atopy

· Chronic cough

· Dental enamel loss

· Globus sensation

· Hoarseness

· Noncardiac chest pain

· Recurrent laryngitis

· Recurrent pharyngitis

· Subglottic stenosis

Complications

About 60% of cases of GERD can be classified as non-erosive reflux disease (NERD). Unfortunately, symptom frequency, duration, and severity do not help to differentiate the grade of esophagitis and cannot be used to reliably diagnose complications of GERD.

Quality of life

Patients who have GERD generally report decreased quality of life, reduced productivity, and decreased well-being. In many patients, reported health-related quality of life is lower than age-matched patients who have untreated angina pectoris, diabetes mellitus or chronic heart failure.

COMPLICATIONS AND ALARM SIGNS

TEACHING

You and Dr. Medel discuss complications of GERD and PUD.

Dr. Medel tells you about alarm symptoms, concluding, "Mr. Rodriguez does not demonstrate any of these right now, but we should remember them, because any of these symptoms would warrant timely referral to a gastroenterologist for endoscopy."

TEACHING POINT

Complications of GERD and PUD

GERD

· Esophagitis develops when the mucosal defenses that normally counteract the effect of injurious agents are overwhelmed by refluxed acid, pepsin, or bile.

· Peptic strictures from fibrosis and constriction occur in about 10 percent of patients with reflux esophagitis.

· Replacement of the squamous epithelium of the esophagus by columnar epithelium (Barrett's esophagus) may result from reflux esophagitis. Two to five percent of cases of Barrett's esophagus may be further complicated by adenocarcinoma.

PUD

· Hemorrhage  or  perforationinto the peritoneal cavity or adjacent organs may occur, causing severe, persistent abdominal pain.

· Duodenal ulcer, inflammation, and fibrotic scarring can impair gastric emptying due to gastric outlet obstruction.

TEACHING POINT

Alarm Symptoms Warranting Referral to Gastroenterology for Endoscopy

Dysphagia	Difficulty in swallowing. Dysphagia to solids suggests possible peptic stricture. Rapidly progressive dysphagia potentially indicates carcinoma. Dysphagia to liquids suggests a motility disorder. Dysphagia to both solids and liquids suggests obstruction—for example, achalasia (closed LES) or tumor.
Initial onset of upper GI symptoms after age 50	Increased chance of cancer.  Older age at onset increases likelihood of organic disease (PUD, cancer) rather than functional dyspepsia or non-erosive reflux disease (NERD). NERD meets the same diagnostic criteria as GERD but shows no erosions on endoscopy.
Early satiety	May be associated with gastroparesis or gastric outlet obstruction (stricture or cancer).
Hematemesis	Vomiting blood suggests bleeding ulcer, mucosal erosions (erosive gastritis/esophagitis), esophageal tear (Mallory-Weiss), or esophageal varices.
Hematochezia	Passing red blood with stool may indicate a rapidly bleeding ulcer or mucosal erosions.
Iron deficiency anemia	The presence of hematemesis, hematochezia, and/or iron deficiency anemia may indicate possible bleeding from a peptic ulcer, mucosal erosions, or cancer.
Odynophagia	Painful swallowing, which is associated with infections (e.g., candida, CMV, HSV), erosions, or cancer.
Recurrent vomiting	Suggestive of gastric outlet obstruction.
Weight loss	Associated with malignancy.

PREPARING FOR THE PHYSICAL EXAM

TEACHING

Now Dr. Medel says, "Let's think about how the physical exam might help us narrow our differential. What do you think?"

"That's a trick question!" you exclaim. "In most cases of patients presenting with symptoms related to GERD and PUD, the physical examination will be normal. But we will want to look for signs of complications."

Dr. Medel replies, "You're right. We will want to look for signs of complications, as well as signs of other diseases that could be associated with dyspepsia."

TEACHING POINT

GERD/PUD Physical Exam: Signs of Complications or Other Associated Diseases

Hemodynamic status	Hypotension or tachycardia may indicate significant blood loss from a gastrointestinal bleed.
Signs of anemia	Brittle nails and cheilosis (cracks and sores on the lips) are signs of anemia. Pallor of palpebral (eyelid) mucosa or nail beds may also be present with anemia. Tachycardia or heart murmur can be a sign of anemia.
Signs of malignancy	Weight loss, palpable mass, presence of signal lymph nodes (Virchow node), and acanthosis nigricans (velvety, hyperpigmented skin, usually on the neck, under the arms, or in the groin) are signs of possible malignancy.
Signs of gallbladder disease	Jaundice or a positive Murphy's sign. A test for Murphy's sign is performed by asking the patient to breathe out and then gently placing the hand in the approximate location of the gallbladder. The patient is then instructed to inspire. If the patient stops inhaling (as the tender gallbladder comes in contact with the examiner's fingers) the test is considered positive.
Signs of hypo or hyperthyroidism	Constipation, cool or pale skin, coarse hair, or non-pitting edema (myxedema) or delayed relaxation phase of deep tendon reflexes (DTRs) may be present in hypothyroidism. Diarrhea, warm skin, thinning hair, eyelid lag, brisk DTRs, or tachycardia may be present in hyperthyroidism. Though a very rare cause of dyspepsia, thyroid disease should be considered.

PHYSICAL EXAM

You knock on the door and ask Mr. Rodriguez if he is ready for you, Lola, and Dr. Medel to re-enter the exam room. Mr. Rodriguez says "Yes," and you proceed with your exam, which reveals:

Vital signs:

· Temperature is 36.9 C (98.5 F)

· Pulse is 78 beats/minute, regular

· Respiratory rate is 16 breaths/minute

· Blood pressure is 123/72 mmHg

· Body mass index is 24.8 kg/m2

General: Well-appearing, middle-aged man.

Head, eyes, ears, nose, and throat (HEENT): Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality.

Neck: Supple, no mass, lymphadenopathy, or thyromegaly.

Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops.

Respiratory: Bilaterally clear to auscultation and percussion without wheezes, rales or rhonchi.

Abdominal: Symmetric appearance without scars or ecchymosis. Normoactive bowel sounds heard in four quadrants. Soft, nondistended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no herniae or masses.

Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions.

Extremities: Warm and well-perfused, no cyanosis, clubbing or edema.

You inform Mr. Rodriguez that his symptoms and physical examination so far do not seem to indicate a serious medical problem and tell him that you are going to step out to give him a chance to dress. Seeing Mr. Rodriguez relax a bit in his chair, you feel that he seems somewhat reassured.

DIAGNOSIS AND TREATMENT PLAN

MANAGEMENT

You and Dr. Medel discuss your findings and consider a diagnosis and treatment plan. She agrees with your assessment that it is challenging to accurately diagnose Mr. Rodriguez with either non-ulcer dyspepsia, GERD or PUD, or gastritis given the history and exam findings alone.

Dr. Medel asks

"Is there anything about Mr. Rodriguez today that seems to be an urgent concern?"

Question

Next, she asks: "Which two of the following options are the most appropriate first steps in diagnostic testing and therapeutic planning for this patient?" Choose the two best answers.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Using an empiric treatment strategy with a proton pump inhibitor (PPI)

· B. Referring the patient for an upper endoscopy (esophagogastroduodenoscopy / EGD)

· C. Ordering an upper GI series (barium swallow radiograph)

· D. Focusing on lifestyle modifications to promote symptomatic improvement

· E. Referring the patient for a 24-hour pH probe

SUBMIT

Answer Comment

The correct answers are A, D.

TEACHING POINT

Empiric Treatment for GERD, Gastritis, and PUD

An empiric treatment strategy for GERD, gastritis, and PUD is the most widely accepted initial therapeutic intervention in patients without red flag symptoms.

The empiric treatment strategy for a patient who exhibits the classic symptomatology of GERD with heartburn and regurgitation begins with a self-directed trial of over-the-counter anti-secretory therapy, either a histamine-2 receptor antagonist or a proton-pump inhibitor (PPI). Many patients consult their primary care physicians because their symptoms have persisted, or because they would like a prescription, which may reduce their out-of-pocket cost for anti-secretory therapy.

Several randomized trials have demonstrated that the "PPI test," defined as a short-term trial of prescription-strength PPI, is both sensitive and specific for diagnosing GERD in patients with classic symptoms and can significantly reduce the need for upper endoscopy/EGD and 24-hour pH monitoring. This test has been shown to save over $350 per patient evaluated, reduce upper endoscopies by 64%, and reduce the number of esophageal monitoring tests by 53%.

The natural history of both GERD and nonulcer dyspepsia are variable, and antisecretory therapy should be stopped after a successful four- to eight-week course, or used in a pulse dose manner (daily for short periods of time when symptoms recur).

Addressing lifestyle modifications with patients who report symptoms of GERD and dyspepsia is a reasonable approach to therapy. There is reported benefit in some patients and expert opinion suggests that dietary/lifestyle changes be encouraged in patients with GERD, although there is little evidence to support improvement in symptomatic outcomes in the absence of pharmacotherapy.

Patients should be referred for upper endoscopy/EGD in the setting of alarm or extraesophageal symptoms to rule out significant disease, or in cases that do not respond to empiric treatment strategy after eight weeks.

The upper GI series can be useful in determining complications of GERD (e.g. esophageal stricture), but has poor utility in diagnosing GERD and should not be used for this purpose. In some cases, the upper GI series may reveal a gastric or duodenal ulcer, but it is not the gold standard test to make this diagnosis.

The 24-hour pH probe is most appropriately utilized when the diagnosis of GERD cannot easily be determined, when patients desire referral for surgical treatment of their GERD/hiatal hernia (Nissen fundoplication) or when patients with classic symptoms of GERD (heartburn, regurgitation) do not improve after appropriate trials of several different PPIs.

SHARING TREATMENT PLAN

Together, you, Dr. Medel and Lola re-enter Mr. Rodriguez's room. You tell him, "At this point, it seems most likely that you may either have some acid from your stomach that is irritating your esophagus, the tube that connects your mouth and stomach, or that you might have irritation from acid in your stomach, ibuprofen, or infection in your stomach, which may have caused an ulcer." Mr. Rodriguez appears startled at the word "ulcer," and he becomes visibly more worried as you finish your sentence.

You take a moment to ask him,

"It seems like something I've said made you nervous. Did it?"

You reply, "I'm sorry, I didn't mean to upset you. While we want to carefully consider possible causes, we don't think your symptoms today represent a serious condition."

You add, "Sometimes people may experience other symptoms that might indicate more serious disease." You review the alarm symptoms of potential complications warranting referral to a gastroenterologist with him, asking him to let you know right away if he experiences any of these symptoms. You also give him a  patient handout in Spanish .

You tell Mr. Rodriguez that a medication called omeprazole may help reduce or take away his pain and heal a possible ulcer. You instruct him to take 20 mg every day for four weeks, on an empty stomach, 30 minutes prior to the first meal of the day. You also suggest that he cut back on alcohol, caffeine, spicy foods, and ibuprofen, substituting acetaminophen instead. Mr. Rodriguez repeats the instructions back to you correctly after you ask him to do so.

Mr. Rodriguez thanks you adding, "I feel a little better about things, but I'm not sure I can pay for the medication. Do you have any samples in your office?"

You tell him, "Unfortunately, we do not have any samples to give you, but I can direct you to Marcia, one of our nurses, who can help get this medication for you through a patient assistance program."

Mr. Rodriguez thanks you for your help, and you recommend a follow-up visit in one month to check on his progress.

MODIFYING TREATMENT PLAN

Mr. Rodriguez returns to the clinic four weeks later. You greet him and Lola, who has returned to serve as his interpreter.

You ask,

"How have you been feeling since the last visit?"

You remember that Mr. Rodriguez's symptoms were fairly ambiguous and that classic symptoms of GERD are more specific, so you try to clarify,

"Do you have any burning in your chest after meals or feel like your food is coming back up after you eat it?"

"Have your original symptoms changed? Did you develop any alarm signs or symptoms from the list I gave you?"

On more detailed questioning and review of his vital signs including weight, you do not elicit any worrisome alarm signs or symptoms from Mr. Rodriguez, but you are concerned that overall his condition has not improved. You excuse yourself for a moment while you go find Dr. Medel.

Question

Should you refer Mr. Rodriguez to a gastroenterologist at this point?

The best option is indicated below. Your selections are indicated by the shaded boxes.

· A. Yes

· B. No

SUBMIT

Answer Comment

The correct answer is B.

Since there are no alarm signs or symptoms suggesting GI bleeding or cancer, a referral to a gastroenterologist is not warranted. Further workup can continue in the office setting.

FOLLOW-UP TREATMENT PLAN

You find Dr. Medel in the hallway and tell her Mr. Rodriguez's symptoms have not improved. You relate that the lack of improvement and the absence of classic symptoms of GERD are making you think GERD is a less likely diagnosis. His past NSAID use makes you wonder if he more likely has PUD, with or without H. pylori infection, although he could still have functional/non-ulcer dyspepsia (NUD) as well.

Dr. Medel agrees with your assessment and asks, "Given that PUD is our next most likely diagnosis at this point, but we are still considering functional dyspepsia, what do you think we should do next?"

H. PYLORI

TEACHING

H. pylori biopsy of gastric antrum, 400x

You and Dr. Medel return to see Mr. Rodriguez and find:

Mr. Rodriguez reports he has not taken any NSAIDs or aspirin since the last visit.

Vital signs:

· Pulse is 80 beats/minute and regular

· Blood pressure is 126/75 mmHg

Abdominal exam: He has minimal epigastric tenderness without rebound or guarding, which is unchanged compared to his previous exam four weeks ago.

Rectal exam: Reveals a negative FOBT test, without any evidence of gross blood or anatomic abnormality.

You excuse yourselves from Mr. Rodriguez's room, reassuring him that you will return shortly.

You tell Dr. Medel, "It's possible that Mr. Rodriguez may have a peptic ulcer, but I don't feel that he needs to be emergently evaluated. He hasn't taken any NSAIDs in over a month, and he doesn't have a history of excessive use. I am concerned that he could have an ulcer or gastritis due to H. pyloriinfection. His history of immigrating from the Dominican Republic places him at a higher risk of having this condition."

TREATING H. PYLORI

TESTING

You and Dr. Medel discuss H. Pylori with Mr. Rodriguez.

Together, you and Dr. Medel decide that you suspect that Mr. Rodriguez may have gastritis or peptic ulcer due to H. pylori.Dr. Medel asks what test should be ordered.

You review the available choices: non-endoscopic-based testing (serology—qualitative or quantitative IgG, stool antigen, urea breath test) and endoscopic-based testing (rapid urease test, gastric biopsy, and tissue culture). You suggest ordering a urea breath test or stool antigen, which are the most sensitive and specific noninvasive tests available, as recommended by the American College of Gastroenterology for the general U.S. population.

Dr. Medel agrees that these are excellent choices, but she reminds you that the patient will have to discontinue his PPI for one to two weeks before he can have these tests done due to their suppressive effects on H. pylori. She also explains that there is a much higher prevalence of H. pylori infection in the immigrant population served by the clinic, which increases the positive predictive value of serologic testing, and that the specificity of the commercial ELISA test being used at the clinic approaches 100%. Though she agrees that serology does not discern active infection from prior exposure, it is less expensive, more convenient for the patient, and has been shown to be an effective test in the primary care workup of younger patients who have no indications for endoscopy. Therefore, she recommends starting with a serologic test for H. pylori with Mr. Rodriguez.

You discuss this infection with Mr. Rodriguez, highlighting that he could have contracted H. pylori as a child and remained asymptomatic for years, that it is common in developing countries like the Dominican Republic, and that it is a treatable condition. You ask him if he has ever heard of H. pylori, and whether or not he has ever been treated for it. He replies that he hasn't. You tell him that you plan to order a blood test to evaluate his exposure to H. pylori.

You order an H. pylori IgG serology and let him know you'll call him when the results are ready.

The next day, you and Dr. Medel are reviewing laboratory results. You notice that Mr. Rodriguez's H. pylori IgG assay is positive:

HELICOBACTER PYLORI IgG ANTIBODY BY EIA—QUALITATIVE

Result: POSITIVE

------------------INTERPRETATION--------------------

NEGATIVE..... No H. pylori IgG antibody detected

POSITIVE..... H. pylori IgG antibody detected

You have the nurse call Mr. Rodriguez to ask him to come in and discuss the results.

TEACHING POINT

First-Line Treatment for H. pylori

"Triple therapy" for 10 to 14 days (70% to 85% eradication rate):

· PPI standard dose twice daily (esomeprazole is dosed once daily)

· Amoxicillin 1 g twice daily

· Clarithromycin 500 mg twice daily

"Quadruple therapy" for 10 to 14 days (75% to 90% eradication rate):

· PPI standard dose once or twice daily

· Metronidazole 250 mg four times daily

· Tetracycline 500 mg four times daily

· Bismuth subsalicylate 525 mg four times daily

An alternative 10-day to 14-day triple regimen to consider in patients who are allergic to penicillin (70% to 85% eradication rate):

· PPI standard dose twice daily

· Clarithromycin 500 mg twice daily

· Metronidazole 500 mg twice daily

FOLLOW-UP VISIT 2

Mr. Rodriguez returns four weeks later. He states that his symptoms of dyspepsia initially improved somewhat after finishing the medication but have since recurred, occurring almost daily. He confirms he took all of the medication exactly as directed without any side effects other than mild diarrhea, which has resolved. Again, he reports no alarm symptoms of complicated upper GI disease.

Question

Which of the following options are appropriate next steps in evaluation and treatment? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Prescribe a PPI once daily for 4 weeks, then reevaluate

· B. Refer for an upper endoscopy/EGD and biopsy

· C. Obtain an H. pylori fecal antigen test

· D. Obtain a urea breath test

· E. Repeat a course of PPI triple therapy for 14 days

· F. Treat with salvage therapy for resistant H. pyloriinfection

SUBMIT

Answer Comment

The correct answers are C, D.

It has now been over four weeks since Mr. Rodriguez was treated with initial pharmacotherapy for H. pylori gastritis.

TEACHING POINT

Evaluation of Persistent Symptoms of Dyspepsia—Investigating H. pyloriEradication

The fecal antigen test and urea breath test are reasonable next steps to evaluate eradication of H. pylori.

1. The fecal antigen test involves collection of a stool sample the size of an acorn by either the clinician or the patient; the sample is then analyzed in a laboratory by trained personnel.

2. The urea breath test requires specialized equipment and patient preparation.

Both tests have been reported to have a sensitivity and specificity for active H. pylori infection of > 90%. The H. pylorifecal antigen test is less expensive and may be more cost-effective than the urease breath test.

· If the fecal antigen test or the urea breath test is positive, the patient will require re-treatment for a resistant infection, but this should not be given prior to testing for the presence of active H. pylori infection.

· If the fecal antigen test or urea breath test is negative, and the patient continues to have symptoms, he should be referred to a gastroenterologist for an upper endoscopy/EGD and mucosal biopsy.

MODIFYING TREATMENT PLAN

You obtain an H. pylori fecal antigen test on Mr. Rodriguez, which is positive. Through Lola, you explain to Mr. Rodriguez that the original medication regimen you gave him probably did not cure his H. pyloriinfection, and that this happens 20% to 30% of the time.

Mr. Rodriguez asks, "Can it be cured? My family is here with me from the Dominican Republic. Should they be tested too?"

Dr. Medel replies, "We will give you an additional medication regimen that will hopefully work. Your family members do not need to be tested or treated unless they have symptoms like yours."

He says, "I'm worried that I will always have these symptoms. Sometimes my pain is very bad, but sometimes it gets better if I drink some milk or eat a meal." Again, he reports no alarm symptoms of complicated upper GI disease but does continue to report episodic epigastric pain.

You prescribe levofloxacin triple therapy and work with Monica to help Mr. Rodriguez obtain these medications through a voucher program.

Dr. Medel suggests that Mr. Rodriguez return to the clinic after completion of therapy.

FOLLOW-UP VISIT 3

Mr. Rodriguez returns two weeks after the completion of salvage therapy for H. pylori gastritis. Through Lola, he tells you that he is completely symptom free!