DDSEP Quick Quiz

DDSEP® 8 Quick Quiz - March 2018 Question 1

A 37-year-old man with no significant past medical history presents with a dull, nonradiating epigastric pain for 3 months. The pain is not associated with eating or positional changes. He denies any heartburn, regurgitation, chest pain, nausea, vomiting, dysphagia, odynophagia, or weight loss. He currently does not take any medications or supplements. Social and family history are not significant. Physical examination reveals minimal tenderness to deep palpation in the epigastrum, but otherwise it is unremarkable. A complete blood count reveals a white blood cell count of 6, hemoglobin 10 g/dL, MCV 72 fL, and platelet count of 200 x 103/mcL. What is the most important next step of management?

DDSEP® 8 Quick Quiz - March 2018 Question 1

A. Schedule an abdominal ultrasound

B. Send an Helicobacter pylori stool antigen

C. Schedule an upper endoscopy

D. Empiric antisecretory therapy

E. Start amitriptyline 25 mg daily

Q1. Correct answer: C

Rationale
The initial management of dyspepsia depends on symptoms and presence of any “alarm features.” In patients without “alarm features” presenting with symptoms suggestive of hepatobiliary or pancreatic causes, the initial diagnostic tests should include liver/pancreatic blood tests and abdominal imaging. For other dyspeptic patients without alarm features, initial management would include H. pylori testing (breath, stool antigen, or antibody) and/or empiric antisecretory (PPI) therapy. However, for patients who present with “alarm features” such as dysphagia, anemia, GI bleeding, anorexia, significant weight loss, etc., an upper endoscopy should be performed to evaluate for the presence of any upper GI tract malignancy. In this patient, the presence of microcytic anemia is an alarm feature. Tricyclic antidepressants such as amitriptyline may be used as treatment for functional dyspepsia, after organic causes have been ruled out.

Reference
1. Talley N.J., Vakil N.B., Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 2005;129:1756-80.

Next Article: