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 Typical symptoms with a normal endoscopy and negative Helicobacter testing, and it is a diagnosis of exclusion. Hunger pain relieved by food in a 34 year old with no alarm features makes it plausible.
2. Gastric cancer Weight loss, early satiety, an epigastric mass or iron deficiency in an older patient, and it is what the referral thresholds exist to catch. Hunger pain relieved by food in a 34 year old with no alarm features raises it.
3. Peptic ulcer disease and gastritis correct Correct. Epigastric pain relieved by food and antacids, in a young man with no alarm features. The relief by eating points to a duodenal ulcer.
4. Gastro-oesophageal reflux disease (including Barrett oesophagus) Burning retrosternal discomfort worse on lying flat or bending, often with an acid taste. Hunger pain relieved by food in a 34 year old with no alarm features describes it.
5. Gastrointestinal bleeding (upper and lower GI bleeding) Haematemesis or melaena from an ulcer that has eroded into a vessel. Hunger pain relieved by food in a 34 year old with no alarm features makes it the complication.

The point: Refer urgently for endoscopy where there is dysphagia at any age, or a new upper abdominal mass, or an adult of 55 or over with weight loss and either upper abdominal pain, reflux or dyspepsia. Everyone else with uninvestigated dyspepsia gets test and treat: a urea breath test or stool antigen for Helicobacter, with eradication if positive, and a month of a proton pump inhibitor if negative. Stop the PPI for two weeks and antibiotics for four before testing, or the test comes back falsely negative. Eradication is a PPI with amoxicillin and either clarithromycin or metronidazole for seven days. NSAIDs and Helicobacter are the two causes; aspirin, steroids, SSRIs and anticoagulants all add to the bleeding risk. A bleeding ulcer is scored with Blatchford before endoscopy and Rockall 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 suppression, so no washout is needed and the test can be done now. It is the first step of test and treat.
2. Electrocardiogram For epigastric pain with cardiac risk factors, because an inferior infarct presents this way. Hunger pain relieved by food in a 34 year old with no alarm features makes it prudent.
3. Blatchford score Calculated at presentation with an upper gastrointestinal bleed, and a score of 0 identifies patients who can be managed as outpatients. Hunger pain relieved by food in a 34 year old with no alarm features makes it useful.
4. Full blood count and ferritin Iron deficiency anaemia in an older adult is a referral trigger in its own right and points to slow blood loss. Hunger pain relieved by food in a 34 year old with no alarm features makes it necessary.
5. Urgent upper gastrointestinal endoscopy For dysphagia at any age, an upper abdominal mass, or age 55 or over with weight loss and dyspepsia. Hunger pain relieved by food in a 34 year old with no alarm features meets that.

The point: Refer urgently for endoscopy where there is dysphagia at any age, or a new upper abdominal mass, or an adult of 55 or over with weight loss and either upper abdominal pain, reflux or dyspepsia. Everyone else with uninvestigated dyspepsia gets test and treat: a urea breath test or stool antigen for Helicobacter, with eradication if positive, and a month of a proton pump inhibitor if negative. Stop the PPI for two weeks and antibiotics for four before testing, or the test comes back falsely negative. Eradication is a PPI with amoxicillin and either clarithromycin or metronidazole for seven days. NSAIDs and Helicobacter are the two causes; aspirin, steroids, SSRIs and anticoagulants all add to the bleeding risk. A bleeding ulcer is scored with Blatchford before endoscopy and Rockall 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 vessel at endoscopy, using two methods rather than adrenaline alone. Hunger pain relieved by food in a 34 year old with no alarm features indicates it.
2. Lifestyle advice and antacids as needed For mild intermittent reflux with no alarm features. Hunger pain relieved by food in a 34 year old with no alarm features makes it reasonable.
3. Full-dose proton pump inhibitor for one month For dyspepsia with negative Helicobacter testing, and for healing an ulcer after eradication. Hunger pain relieved by food in a 34 year old with no alarm features meets that.
4. Test and treat for Helicobacter pylori correct Correct. The pathway for uninvestigated dyspepsia without alarm features. Endoscopy here would be a normal test in a young man who does not need one.
5. High-dose intravenous proton pump inhibitor after endoscopy Given after endoscopic treatment of a bleeding ulcer, not before endoscopy, where it changes nothing that matters. Hunger pain relieved by food in a 34 year old with no alarm features makes the timing the point.

The point: Refer urgently for endoscopy where there is dysphagia at any age, or a new upper abdominal mass, or an adult of 55 or over with weight loss and either upper abdominal pain, reflux or dyspepsia. Everyone else with uninvestigated dyspepsia gets test and treat: a urea breath test or stool antigen for Helicobacter, with eradication if positive, and a month of a proton pump inhibitor if negative. Stop the PPI for two weeks and antibiotics for four before testing, or the test comes back falsely negative. Eradication is a PPI with amoxicillin and either clarithromycin or metronidazole for seven days. NSAIDs and Helicobacter are the two causes; aspirin, steroids, SSRIs and anticoagulants all add to the bleeding risk. A bleeding ulcer is scored with Blatchford before endoscopy and Rockall after it.

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