What is the best next step in managing a 55-year-old woman's progressive abdominal pain, nausea, and feeling of fullness, with a history of hypertension, osteoarthritis, and long-term use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), including celecoxib (celecoxib), and proton pump inhibitors, such as omeprazole (omeprazole)?

Endoscopy with Biopsy is the Best Next Step

This patient requires urgent upper endoscopy with biopsy to evaluate for peptic ulcer disease, gastric malignancy, and H. pylori infection, given her alarm features of significant weight loss, progressive symptoms despite PPI therapy, and chronic NSAID use. 1, 2, 3

Clinical Reasoning

This 55-year-old woman presents with multiple red flags that mandate endoscopic evaluation:

• Progressive epigastric pain worsening despite omeprazole 20 mg daily suggests either inadequate acid suppression, NSAID-induced ulceration, or potentially malignancy 3
• Significant unintentional weight loss of 9.1 kg (20 lb) over 6 months is an alarm symptom requiring prompt endoscopic evaluation to exclude gastric malignancy 2, 3
• Early satiety and postprandial pain pattern are concerning for peptic ulcer disease or gastric outlet involvement 2
• Chronic celecoxib use (200 mg daily) places her at moderate-to-high risk for NSAID-induced gastroduodenal injury, even with concurrent PPI therapy 4, 5

Why Endoscopy Over Other Options

Upper GI Series (Option A) is Inadequate

• Barium studies cannot provide tissue diagnosis, assess for H. pylori infection, or definitively rule out malignancy 1, 2
• The American Gastroenterological Association recommends endoscopy for patients taking NSAIDs who present with dyspeptic symptoms, as it can diagnose potentially life-threatening ulcer complications 3

H. pylori Breath Test Alone (Option C) is Insufficient

• While H. pylori testing is essential, it should be performed during endoscopy via biopsy in this patient with alarm features 1, 2
• Testing for H. pylori should be done in all patients with suspected peptic ulcer disease, but endoscopy allows simultaneous visualization, biopsy for malignancy exclusion, and direct assessment of ulcer severity 2, 3
• H. pylori increases NSAID-related complications by 2-4 fold, making eradication crucial if present 3

Critical Management Points

Immediate Actions Required

• Discontinue celecoxib immediately - NSAIDs significantly increase the risk of ulcer recurrence and complications even with PPI therapy 3, 5
• Increase omeprazole to 40 mg once daily while awaiting endoscopy 3
• Switch to acetaminophen for pain control as it does not cause gastric injury 3

Endoscopic Evaluation Will Provide

• Direct visualization of gastroduodenal mucosa to identify ulcers, erosions, or masses 1, 2
• Tissue biopsy to exclude malignancy (critical given weight loss) and test for H. pylori 2, 3
• Assessment of ulcer severity using Forrest classification if bleeding ulcer present 1
• Therapeutic intervention if active bleeding is encountered 1

Post-Endoscopy Management Strategy

If NSAID-Induced Ulcer is Found

• Continue high-dose PPI (omeprazole 40 mg once daily or equivalent) for 8 weeks to ensure complete healing 1, 2, 3
• Never resume NSAIDs - patients with NSAID-induced ulcers are at very high risk for recurrent complications 3
• If anti-inflammatory therapy is absolutely necessary in the future, use celecoxib combined with PPI, though this remains high-risk 4

If H. pylori is Positive

• Initiate eradication therapy with triple therapy: PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 2, 3
• H. pylori eradication prevents recurrent bleeding and ulcer recurrence 2

If Malignancy is Found

• Urgent oncology referral and staging workup 2

Common Pitfalls to Avoid

• Do not delay endoscopy for empiric H. pylori testing - alarm features mandate direct visualization 1, 2, 3
• Do not continue celecoxib even with PPI therapy - this patient has already failed this strategy with progressive symptoms 4, 5
• Do not assume PPI failure means no ulcer - only one in five patients who develop serious upper GI adverse events on NSAID therapy is symptomatic before complications occur 5
• Do not overlook cardiovascular risk factors when considering future NSAID use - this patient has hypertension and is on hydrochlorothiazide, increasing her risk profile 4, 5