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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #31


Have a patient complaining of dull epigastric pain? Consider an ulceration in your differential.

In an outpatient setting, a peptic ulcer can be diagnosed clinically. Here is how:

Inquire if the patient is also having abdominal bloating/fullness, acid reflux, belching, and/or burping. Also ask if they have been taking any NSAIDs or
steroids recently.

Another key diagnostic question is to ask them if the pain could be described as a “hunger pain” that is resolved with food. An individual with a peptic ulcer will usually state their pain goes away after they eat for 1-2 hours and then it returns. An individual with a duodenal ulcer will state the pain worsens 1-2 hours after they eat.

Virtually all peptic ulcers are caused by h. pylori or NSAID use. I will start my patients on omeprazole or pantoprazole daily for 6 weeks and sucralfate 20 minutes before meals for 5-7 days. The symptoms typically will resolve in 3-5 days.

Make sure you also test for h. pylori via urea breath testing, stool antigen assay or serology. Treatment of h. pylori is straight forward and curative.

If conservative treatment fails after 1-2 weeks, refer the patient to GI for endoscopy.

As always, use your clinical judgement.

3 Responses

  1. Before the breath test or stool sample, patients should not be on PPI for one to two weeks. Do you test them first then start them on your treatment course?

    1. It solely on depends their presentation. If they have a history of NSAID use, then no I do not see a point in testing. On the other hand, if they have no significant risk factors then I will start with h. pylori testing before treatment. No point in starting someone on 6 weeks of PPI to only have symptoms return.

  2. I would recommend testing for h pylori before starting ppi treatment as the meds may result in false negative test results

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