A 33 year old woman presents to your ED complaining of 4 days of “stomach pain.” She says it started after a weekend of mandatory celebratory drinking for closing a deal at her fancy finance job, and that she had been super stressed at work before the deal closed. She says the pain is epigastric, intermittent usually an hour after eating, and feels like a dull gnawing pain in the middle of her upper abdomen. Overnight the pain woke her from sleep at 3am. On further questioning, she’s also been throwing back OTC “pain killers” for an ankle injury she sustained playing competitive water polo.
She denies nausea, vomiting, fevers, etc. Her vital signs are textbook normal, she is well-appearing, and her exam is only significant for mild epigastric tenderness.
Before you go jumping to your diagnosis, what's the differential and how can you narrow? Gastritis, GERD, PUD, AAA, pancreatitis, hepatitis, biliary colic, choledocolithiasis, or cardiac causes. After you make sure she has no signs of a GI Bleed / anemia / abnormal liver tests, get your normal EKG, and throw that sono probe on her to rule out gallbladder pathology or AAA, you’re happy with your clinical diagnosis of… Peptic Ulcer Disease!
What is your next step: urgent endoscopy, fecal H. pylori testing, 'take 2 aspirin and you'll feel better in the morning,' triple therapy, or PPI alone?ED workup for stable PUD has no business with poop testing for H.Py or emergent endoscopy. You should prescribe a PPI and give strict instructions against taking drinking or popping NSAIDs, and make sure she follows up with her PMD or a GI specialist.
A wee bit more about your diagnosis PUD includes gastric ulcers and duodenal ulcers. The top 2 causes are
H. pylori infection and chronic NSAID use.
- H. Pylori releases factors that cause gastric tissues injury and inflammation. Up to 40% of the population is colonized but only ~10% of those infected develop PUD. Infection is related to lower socioeconomic status, especially living conditions during childhood. Diagnosis includes serum antigen testing, fecal antigen testing, urea breath test, or endoscopic biopsy testing… none of which you will do in our fine ED.
- NSAIDs cause ulcers through suppression of gastric prostaglandin synthesis. Any patient on NSAIDs with another risk factor (elderly, on steroids, history of PUD, high NSAID doses) should be on a prophylactic PPI.
- PUD classically awakes patients at night when gastric secretion is highest (around 3am). The pain can be initially relieved with food but ten returns with emptying.
- Classic treatment is PPI or H2-blocker, with antacids for breakthrough pain. If these do not receive symptoms after a week, patients should follow-up for endoscopy or definitive H. pylori testing.
Refs and such
Rosen’s Emergency Medicine. Hess, J and Lowell M, Chapter 89.
Tintinalli’s 7th Ed. Gratton M, Chapter 81
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Emergency Medicine Resident at Kings County Hospital / SUNY Downstate
@KBirnbaumMD
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