Patient With Sudden Onset of Intermittent Mid-Epigastric Pain
PR is a 35-year-old female who presents with a sudden onset of intermittent mid-epigastric pain that started 4 weeks ago. Pain is 6/10 on the pain scale and described as burning that worsens after she eats Mexican food and when she is lying down. She has never experienced this before. PR reports that she has been taking over the counter (OTC) antacids that seemed to help at first, but now they provide no relief. She reports associated regurgitation and feeling of fullness all the time and this morning she had a sore throat.
Past Medical History
• Anaphylactic reaction to penicillin Medications
• OTC antacids
Family History
• Noncontributory
Social History
• Occupation: Elementary school teacher (10 years)
• Nonsmoker
• Denies illicit drug use
• Consumes wine two to three times per month •
Regular exercise
Physical Examination
• Weight: 145 lbs.; blood pressure: 128/72; pulse: 80; respiration rate: 18; temperature: 98.7 °F
• General: Calm, cooperative, in no apparent distress
• Eyes: Pupils equal, round, reactive to light
• Ears: Tympanic membranes clear
• Nares: Without nasal septal deviation; pharyngeal mucosa pink and moist
• Throat: Oropharynx without edema, erythema, tonsillar enlargement, lesions
• Abdomen: Nondistended, soft, round, nontender; normoactive bowel sounds in all quadrants
Discussion Questions
1. What are the top three differential diagnoses for PR?
2. What diagnostic tests if any are required for PR?
3. What pharmacological nonpharmacological and/or nutraceutical therapies should be prescribed for PR?
4. The results from PR’s H. pylori test returned positive. What treatment should be added to her plan of care?
Based on PR’s presentation and symptoms, here are the answers to the discussion questions:
1. Top Three Differential Diagnoses for PR
Gastroesophageal Reflux Disease (GERD):
- Rationale: The burning pain that worsens after eating and when lying down, along with regurgitation and a sore throat, are classic symptoms of GERD.
Peptic Ulcer Disease (PUD):
- Rationale: The intermittent epigastric pain described as burning and worsened by certain foods could indicate an ulcer. The use of OTC antacids providing initial relief also aligns with this diagnosis.
Functional Dyspepsia:
- Rationale: The feeling of fullness and epigastric pain without any obvious structural cause can point towards functional dyspepsia, especially given that the physical examination is largely unremarkable.
2. Diagnostic Tests for PR
Upper Endoscopy (EGD):
- Purpose: To visualize the esophagus, stomach, and duodenum for any signs of inflammation, ulcers, or other abnormalities.
H. pylori Testing:
- Purpose: Since H. pylori infection is a common cause of peptic ulcers, this test is crucial. Methods include urea breath test, stool antigen test, or endoscopic biopsy.
Esophageal pH Monitoring:
- Purpose: To assess acid exposure in the esophagus over a 24-hour period, which can help confirm GERD.
3. Pharmacological, Nonpharmacological, and Nutraceutical Therapies
Pharmacological:
- Proton Pump Inhibitors (PPIs): Such as omeprazole, to reduce stomach acid and promote healing.
- H2 Receptor Antagonists: Such as ranitidine or famotidine, if PPIs are not well-tolerated.
- Antacids: For quick relief of symptoms.
Nonpharmacological:
- Dietary Modifications: Avoiding trigger foods (e.g., spicy foods, alcohol, caffeine), eating smaller meals, and avoiding eating before lying down.
- Lifestyle Changes: Elevating the head of the bed, losing weight if overweight, and avoiding smoking.
Nutraceutical:
- Probiotics: To support gastrointestinal health.
- Deglycyrrhizinated Licorice (DGL): To help soothe and protect the stomach lining.
4. Treatment Plan for Positive H. pylori Test
For a positive H. pylori test, the following treatment regimen should be added:
Triple Therapy:
- PPI (e.g., omeprazole): Twice daily.
- Clarithromycin: 500 mg twice daily.
- Amoxicillin: 1 g twice daily.
Given PR’s history of an anaphylactic reaction to penicillin, use metronidazole (500 mg twice daily) instead of amoxicillin.
This treatment should typically be continued for 10-14 days, followed by a reassessment to confirm eradication of the infection.
Summary
PR presents with symptoms that suggest GERD, PUD, or functional dyspepsia. Diagnostic testing should include an upper endoscopy and H. pylori testing. Treatment should start with PPIs, lifestyle modifications, and dietary adjustments. Given the positive H. pylori result, appropriate antibiotic therapy should be initiated, taking into account her allergy history.