A 41-year-old woman is evaluated for a 4-month history of intermittent mid-upper-abdomen pain, which does not radiate and is not affected by eating. She had gastroesophageal reflux when she was pregnant, but she says that the current symptoms are not like those of reflux or heartburn. She occasionally feels nauseated and mildly bloated, but she has not vomited, felt early satiety, or lost weight. She does not have difficulty swallowing or painful swallowing. Her bowel movements are normal. She has been pregnant twice and had two healthy children, both delivered by cesarean section. Her medical history also includes a cholecystectomy 5 years ago. Her only current medication is a multivitamin.
On physical examination, she is afebrile; the pulse rate is 65/min and the blood pressure is 110/65 mm Hg. There is no jaundice or scleral icterus; mild epigastric tenderness is present. Bowel sounds are normal; there are no abdominal bruits, palpable masses, or lymphadenopathy. Complete blood count and liver chemistry tests are normal.
Which of the following is the most appropriate next diagnostic test in the evaluation of this patient?
Answer and Critique (Correct Answer: D)
Educational Objective:Evaluate dyspepsia.
- In patients younger than 55 years who have new-onset dyspepsia without alarm symptoms, a “test and treat” approach for Helicobacter pylori is recommended.
This patient has new-onset uninvestigated dyspepsia. In a patient younger than 55 years without alarm features, the recommendation is to “test and treat” for Helicobacter pylori infection. The H. pylori stool antigen test detects active infection and therefore can be used in the initial diagnosis as well as for eradication testing.
An abdominal ultrasonography can be used in the evaluation of presumed biliary colic or chronic mesenteric ischemia (the latter if Doppler evaluation is additionally performed). The likelihood of biliary disease in this patient who is post-cholecystectomy and who has normal serum chemistry tests is low. Chronic mesenteric ischemia is also very unlikely because her pain does not increase with eating, and she has not lost weight, has no known risk factors for atherosclerosis, and has no abdominal bruits. An esophagogastroduodenoscopy is not needed given her age and lack of alarm features, but the procedure could be considered if her symptoms persist after H. pylori treatment. Gastric scintigraphy is used in the evaluation of gastroparesis and should only be performed after mechanical obstruction has been ruled out with upper endoscopy or barium radiography. The patient’s predominant symptom is pain and she has not vomited or had early satiety, and therefore, dyspepsia is more likely than gastroparesis. Although this patient has had several abdominal surgeries putting her at risk for a small-bowel obstruction from adhesions, the fact that her pain does not worsen with eating, she has not vomited, has maintained normal bowel movements, and has normal bowel sounds make obstruction unlikely; therefore, a small-bowel radiograph would be unnecessary at this point.
- Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia. Gastroenterology. 2005;129(5):1756-1780. [PMID:16285971] - See PubMed
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