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Old 10-30-2011
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GIT peptic ulcer

A 54-year-old woman comes to your clinic as follow-up after endoscopic treatment for a single bleeding peptic ulcer. Her peptic ulcer became clinically apparent 2 weeks before this visit when the patient noted subacute abdominal pain followed by small-volume coffee-ground emesis. After endoscopy, her 2-day hospital stay was uneventful. She remained hemodynamically stable and required no blood transfusions. Besides a history of a misdiagnosed perforated appendix in her 20s, the remainder of her medical history is negative. Because she has been feeling well and has “much less stress” in her life, she has not felt the need to take any medicines since her hospitalization, except for green teas as suggested by a friend. She has no allergies. She has a family history for hypertension and cardiac disease in her father. She does not smoke or drink alcohol. She is in a monogamous relationship and works as a book publisher. Her physical examination is normal except for the obvious old, healed appendectomy scar. Besides suggesting age-appropriate medical screening, which of the following should you recommend?
A. Avoidance of caffeinated beverages
B. Complete blood count
C. Chronic proton pump inhibitor treatment only
D. Empiric treatment for Helicobacter pylori infection
E. Repeat endoscopy
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A_a_ (10-31-2011), pass7 (10-31-2011)

Old 10-31-2011
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empiric treatment for H.pylori shud be given a chance. because the person doesnt have any other obvious cause of ulcer??
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Old 10-31-2011
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The correct answer is D. In the absence of aggravating factors, multiple ulcers, or a neoplastic process, there exists such a strong causative role of H. pylori colonization in peptic ulcer disease (PUD) that some have argued that PUD be considered an “infectious disease.” Strong recommendations exist to treat for H. pylori in cases of known duodenal or gastric ulcers. In this context, testing for H. pylori in the clinic (e.g., via urea breath test or H. pylori serology) before initiating treatment has not been shown to be cost-effective. It should be pointed out, though, that in the vignette provided here, one could not be faulted for testing for H. pylori if this was provided as one of the possible options. The decision to test for H. pylori in patients who exhibit dyspepsia not associated with ulcers is made on a case-by-case basis. Besides eradicating the etiologic agent for PUD, treatment for H. pylori in patients with a history of PUD may decrease the patient’s risk for developing gastric lymphoma.

Although caffeine decreases the gastric mucosal barrier, it has not been shown that complete avoidance of caffeine (choice A) will preclude development of PUD. The most prudent advice would be to take these beverages in moderation.

A CBC (choice B) is not required if the patient is asymptomatic and has had an uncomplicated clinical course with stable blood counts and no evidence of active bleeding.

The chronic use of a proton pump inhibitor (choice C) in the absence of H. pylori eradication is not warranted in a patient with a known history of PUD. Some physicians will maintain patients who have a history of a bleeding peptic ulcer on PPI therapy once these patients have completed H. pylori treatment. A short course of PPI monotherapy may be considered in the patient with dyspepsia or GERD without known PUD.

Without significant complications at endoscopy or during hospitalization, a repeat endoscopy (choice E) is not needed. There are no generally agreed-upon recommendations for surveillance studies.
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Gastroenterology-, Internal-Medicine-, Step-2-Questions

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