What is the diagnostic plan for a patient with burning epigastric pain, relieved by food and antacids, with a history of smoking, coffee and alcohol consumption, and occasional nonsteroidal anti-inflammatory drug (NSAID) use?

Diagnostic Plan for Epigastric Pain Suggestive of Peptic Ulcer Disease

The most appropriate diagnostic plan for this 42-year-old man with burning epigastric pain is to test for Helicobacter pylori infection and initiate empiric acid suppression therapy while awaiting results. 1

Initial Assessment

• The patient's presentation strongly suggests peptic ulcer disease (PUD) based on classic symptoms: burning epigastric pain occurring 2-3 hours after meals, nocturnal awakening, and relief with food and antacids 1
• Several risk factors for PUD are present: smoking, coffee and alcohol consumption, and occasional ibuprofen use 2
• Epigastric tenderness on examination without right upper quadrant tenderness or jaundice further supports this diagnosis 1

Diagnostic Testing

First-line Testing:

• Test for H. pylori infection using one of the following methods:
  • Urea breath test (preferred non-invasive test) 1
  • Stool antigen test 1
  • Serology (less preferred due to lower accuracy) 1

Endoscopy Indications:

• Endoscopy should be performed if any of these are present:
  • Age >40 years (this patient qualifies at age 42) 1
  • Alarm symptoms (which this patient does not have): dysphagia, odynophagia, GI bleeding, unexplained weight loss, iron deficiency anemia, recurrent vomiting 1
  • Chronic NSAID use (this patient has only occasional use) 1, 3
  • Persistent symptoms despite empiric therapy 1

Endoscopy Protocol:

• Upper endoscopy should include:
  • Visualization of esophagus, stomach, and duodenum 1
  • Biopsy of any visible lesions 1
  • Antral biopsies for H. pylori testing if other tests were not performed 1
  • Multiple biopsies if no obvious ulcer is found to rule out other conditions 4

Empiric Treatment While Awaiting Test Results

• Start proton pump inhibitor therapy (e.g., omeprazole 20 mg once daily) 5
• Advise the patient to:
  • Discontinue or minimize NSAID use 2, 3
  • Reduce alcohol and coffee consumption 1
  • Stop smoking 1
  • Continue using antacids as needed for breakthrough symptoms 6

Management Based on Test Results

If H. pylori positive:

• Initiate triple therapy: omeprazole 20 mg, amoxicillin 1000 mg, and clarithromycin 500 mg, all twice daily for 10-14 days 5
• Continue PPI for an additional 4-8 weeks if ulcer is confirmed on endoscopy 5
• Confirm H. pylori eradication 4 weeks after completing therapy 1

If H. pylori negative:

• Continue PPI therapy for 4-8 weeks 5
• If symptoms persist, consider:
  • Increasing PPI dose (e.g., omeprazole 40 mg daily) 5
  • Adding a prokinetic agent if dysmotility symptoms are present 1

Common Pitfalls to Avoid

• Misdiagnosis of GERD: While symptoms can overlap, the timing of pain (2-3 hours after meals rather than immediately) and location (epigastric rather than retrosternal) favor PUD over GERD 1, 4
• Inadequate H. pylori testing: Testing should be done before starting PPI therapy or at least 2 weeks after discontinuation to avoid false negatives 1
• Overlooking cardiac causes: Although this patient's presentation is typical for PUD, atypical cardiac presentations should be considered, especially with risk factors 1, 4
• Failure to address NSAID use: Even occasional NSAID use can contribute to gastroduodenal damage and should be discontinued 2, 3
• Inadequate follow-up: Patients with persistent symptoms despite appropriate therapy require follow-up endoscopy to rule out other conditions or complications 1

This diagnostic approach prioritizes identifying and treating the most likely cause of this patient's symptoms while ensuring that serious conditions are not missed, ultimately reducing morbidity and improving quality of life.