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Old 11-02-2012
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Arrow Gyrus Daily Questions; Internal Medicine #68

A 56 year old woman comes to the clinic because her symptoms of epigastric pain from endoscopically confirmed duodenal ulcer have not responded to several weeks of PPI, clarithromycin and amoxicillin.

What is the most appropriate next step in the management of this patient ?

a. Refer for surgery.
b. Switch the PPI to ranitidine.
c. Abdominal CT scan.
d. Capsule endoscopy
e. Urea breath testing.
f. Vagotomy
g. Add sucralfate

Last edited by cingulate.gyrus; 11-02-2012 at 04:05 AM. Reason: editing
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Urea breath testing to check for H Pylori
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Urea breath testing and if still postive for H pylori you change medication to metronidazole and tetralcyline
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Add sucrulfate coz if the ulcer not respond to erradication treatment of h.pylori it could b NSAID induced ulcer

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Quote:
Originally Posted by cingulate.gyrus View Post
A 56 year old woman comes to the clinic because her symptoms of epigastric pain from endoscopically confirmed duodenal ulcer have not responded to several weeks of PPI, clarithromycin and amoxicillin.

What is the most appropriate next step in the management of this patient ?

a. Refer for surgery.
b. Switch the PPI to ranitidine.
c. Abdominal CT scan.
d. Capsule endoscopy
e. Urea breath testing.
f. Vagotomy
g. Add sucralfate
E, first you really have to know if the patient has active H.pylori and the easiest and quick way to do so is by an Urea breath testing or a stool sample.

A: You dont refer to surgery if you dont even know what is going on and the patient is stable.
B: H2 blockers are never used and if used they suck compared to PPI's
C: There is no reason to suspect a malignancy or an abscess which would be clear indications for and abdominal CT scan, in either case if you suspect Gastrinoma you would start with serology first.
D: Capsule endoscopy is not the correct answer to anything.
F: I dont remember a case where you would do vagotomy, unless you are dealing with an extremely bizarre or aggressive gastrinoma, which in either case can be treated with high doses of PPI's
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Ideally you check the sample taken during the initial endoscopy for resistant strain of H Pylori. I am not sure why it was not done.
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Answer is E.

Urease breath test.

If there is no response to DU theraphy with PPIs, Clarithromycin and amoxycillin , the first thought should be antibiotic resistence of the organism.

Persistence H pylori infection can be detected with several methods such as urease breath test, stool antigen or repeated endoscopy for biopsy.It would be hard to choose between these.

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Gyrus Daily Questions; Internal Medicine #68-h-pylori-eradication.jpg
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