Photo Rounds

Epigastric pain

A 61-year-old man sought care for the dull, achy, and intermittent epigastric pain that had been bothering him for 4 months. Coffee intake seemed to exacerbate the symptoms while eating or drinking milk helped. The patient said that the pain occasionally awakened him at night. On examination, there was mild epigastric tenderness with no rebound or guarding. Because the patient was over age 55, the family physician sent him for an upper gastrointestinal endoscopy rather than treating him empirically with acid suppression.

What's your diagnosis?


Endoscopy revealed a pyloric ulcer and an erosion of the mucosa. Biopsies showed the presence of Helicobacter pylori.

Peptic ulcer disease (PUD) is characterized by a break in the mucosal lining of the stomach or duodenum secondary to pepsin and gastric acid secretion; this damage is greater than 5 mm in size and the depth reaches the submucosal layer. Note that duodenal ulcers are virtually never malignant and do not require biopsy. However, gastric ulcers (including the pylorus) should be biopsied because 3% to 5% of benign-appearing gastric ulcers prove to be malignant.

The goals of treatment of active H pylori-associated ulcers are to relieve dyspeptic symptoms, promote ulcer healing, and eradicate H pylori infection. Eradication of H pylori is better than drug therapy for duodenal ulcer healing and greatly reduces the incidence of recurrence from 67% to 6% in patients with duodenal ulcers and from 59% to 4% in patients with gastric ulcers.

Four drug combinations currently provide the best results and consist of 2 general combinations: (a) a proton-pump inhibitor (PPI), amoxicillin, clarithromycin, metronidazole/tinidazole given either sequentially or concomitantly, or (b) a PPI, a bismuth, tetracycline HCL, and metronidazole/tinidazole.

In this case, the physician prescribed combination “a” and the patient’s symptoms resolved completely.

Photo courtesy of Marvin Derezin, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Azhary H, Smith M. Peptic ulcer disease. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 365-370.

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