Gastrointestinal for PLAB 1

A 34 year old man has had epigastric pain for three months, worse when hungry and relieved by eating and by antacids. He has no dysphagia, no vomiting and no weight loss. His full blood count is normal and he is on no regular medication. He has taken no acid suppression. What is the SINGLE most likely diagnosis?

1. Functional dyspepsia The usual symptoms with a normal camera test and a negative Helicobacter test; a diagnosis made only once other causes are ruled out. Here, hunger pain relieved by food in a 34 year old with no warning signs points elsewhere.
2. Gastric cancer Weight loss, feeling full quickly, a lump felt in the upper belly, or low iron in an older patient, and this is exactly what the urgent referral rules are meant to catch. It does not fit hunger pain relieved by food in a 34 year old with no warning signs.
3. Peptic ulcer disease and gastritis correct Correct. Pain in the upper belly eased by food and antacids, in a young man with no warning signs. Pain that eases with eating points to an ulcer in the first part of the small bowel.
4. Gastro-oesophageal reflux disease A burning feeling behind the breastbone, worse lying flat or bending over, often with a sour or acid taste. That does not match hunger pain relieved by food in a 34 year old with no warning signs.
5. Gastrointestinal bleeding (upper and lower GI bleeding) Vomiting blood or passing black tarry stool from an ulcer that has eaten into a blood vessel. But hunger pain relieved by food in a 34 year old with no warning signs does not point to it.

The point: Refer urgently for a camera test of the stomach (endoscopy) when there is trouble swallowing at any age, a new lump felt in the upper belly, or an adult of 55 or over with weight loss along with upper belly pain, reflux or indigestion. Everyone else with indigestion that has not been investigated gets test and treat: a breath test or stool test for the Helicobacter pylori germ, with treatment to clear it if positive, and a month of an acid-suppressing drug (a proton pump inhibitor, or PPI) if negative. Stop the PPI for two weeks and antibiotics for four weeks before testing, or the test can come back wrongly negative. Clearing the infection means a PPI with amoxicillin and either clarithromycin or metronidazole for seven days. NSAID painkillers and Helicobacter are the two causes of an ulcer; aspirin, steroids, antidepressants called SSRIs, and blood thinners all add to the risk of bleeding. A bleeding ulcer is scored with the Blatchford score before the camera test and the Rockall score after it.

Source: NICE CG184 — Gastro-oesophageal reflux disease and dyspepsia in adults NICE · tier 1, national regulator or guidance

A 34 year old man has had epigastric pain for three months, worse when hungry and relieved by eating and by antacids. He has no dysphagia, no vomiting and no weight loss. His full blood count is normal and he is on no regular medication. He has taken no acid suppression. What is the SINGLE most appropriate initial investigation?

1. Urea breath test for Helicobacter pylori correct Correct. He has taken no acid-suppressing drug, so there is no need to wait, and the test can be done now. It is the first step of test and treat.
2. Electrocardiogram For upper belly pain with risk factors for heart disease, because a heart attack affecting the bottom of the heart can look like this. It does not fit hunger pain relieved by food in a 34 year old with no warning signs.
3. Blatchford score Worked out when a patient first comes in with a bleed from the upper gut, and a score of 0 identifies patients who can be treated without being admitted. But hunger pain relieved by food in a 34 year old with no warning signs does not point to it.
4. Full blood count and ferritin Low iron in an older adult is, on its own, a reason for urgent referral, and it points to slow, hidden blood loss. Here, hunger pain relieved by food in a 34 year old with no warning signs points elsewhere.
5. Urgent upper gastrointestinal endoscopy For trouble swallowing at any age, a lump felt in the upper belly, or age 55 or over with weight loss and indigestion. That does not match hunger pain relieved by food in a 34 year old with no warning signs.

The point: Refer urgently for a camera test of the stomach (endoscopy) when there is trouble swallowing at any age, a new lump felt in the upper belly, or an adult of 55 or over with weight loss along with upper belly pain, reflux or indigestion. Everyone else with indigestion that has not been investigated gets test and treat: a breath test or stool test for the Helicobacter pylori germ, with treatment to clear it if positive, and a month of an acid-suppressing drug (a proton pump inhibitor, or PPI) if negative. Stop the PPI for two weeks and antibiotics for four weeks before testing, or the test can come back wrongly negative. Clearing the infection means a PPI with amoxicillin and either clarithromycin or metronidazole for seven days. NSAID painkillers and Helicobacter are the two causes of an ulcer; aspirin, steroids, antidepressants called SSRIs, and blood thinners all add to the risk of bleeding. A bleeding ulcer is scored with the Blatchford score before the camera test and the Rockall score after it.

Source: NICE CG184 — Gastro-oesophageal reflux disease and dyspepsia in adults NICE · tier 1, national regulator or guidance

A 34 year old man has had epigastric pain for three months, worse when hungry and relieved by eating and by antacids. He has no dysphagia, no vomiting and no weight loss. His full blood count is normal and he is on no regular medication. He has taken no acid suppression. What is the SINGLE most appropriate immediate management?

1. Endoscopic haemostasis with adrenaline and a second modality For active bleeding or a visible blood vessel seen at the camera test, using two methods together rather than adrenaline on its own. That does not match hunger pain relieved by food in a 34 year old with no warning signs.
2. Stop the NSAID and start a proton pump inhibitor For an ulcer caused by an NSAID painkiller, where stopping the drug matters more than the acid-suppressing medicine. Here, hunger pain relieved by food in a 34 year old with no warning signs points elsewhere.
3. Full-dose proton pump inhibitor for one month For indigestion with a negative Helicobacter test, and for healing an ulcer after the infection has been cleared. But hunger pain relieved by food in a 34 year old with no warning signs does not point to it.
4. Test and treat for Helicobacter pylori correct Correct. The pathway for indigestion that has not been investigated, with no warning signs. A camera test here would just show a normal stomach in a young man who does not need one.
5. Lifestyle advice and antacids as needed For mild reflux that comes and goes, with no warning signs. It does not fit hunger pain relieved by food in a 34 year old with no warning signs.

The point: Refer urgently for a camera test of the stomach (endoscopy) when there is trouble swallowing at any age, a new lump felt in the upper belly, or an adult of 55 or over with weight loss along with upper belly pain, reflux or indigestion. Everyone else with indigestion that has not been investigated gets test and treat: a breath test or stool test for the Helicobacter pylori germ, with treatment to clear it if positive, and a month of an acid-suppressing drug (a proton pump inhibitor, or PPI) if negative. Stop the PPI for two weeks and antibiotics for four weeks before testing, or the test can come back wrongly negative. Clearing the infection means a PPI with amoxicillin and either clarithromycin or metronidazole for seven days. NSAID painkillers and Helicobacter are the two causes of an ulcer; aspirin, steroids, antidepressants called SSRIs, and blood thinners all add to the risk of bleeding. A bleeding ulcer is scored with the Blatchford score before the camera test and the Rockall score after it.

Source: NICE CG184 — Gastro-oesophageal reflux disease and dyspepsia in adults NICE · tier 1, national regulator or guidance