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Suggest Treatment For Intermittent Epigastric Pain
Question: A 42 yo Caucasian male presents with 2-month history of intermittent epigastric pain. The pain sometimes wakes him up at night and seems to get better after he eats a meal. He was told by his doctor about 4 months ago that he had a bacterial infection in his stomach but he never followed up. He has been taking over-the-counter Zantac for 2 weeks without relief but the pain is continuing. He has no other PMH except he is a 20-pack year smoker and he drinks 5 cups of coffee a day. He eats late at night and goes to bed about 30 minutes after a late dinner. He also takes Motrin twice a day for shoulder pain. He is allergic to penicillin.
Im a DNP student and checking to see if Im on the right track to diagnosing and treating.
Im a DNP student and checking to see if Im on the right track to diagnosing and treating.
Brief Answer:
Needs investigation
Detailed Answer:
Hello,
the symptoms may point to duodenal ulcer (relief after eating, night symptoms, bacterial infection in the stomach etc). Zantac should have helped him. Motrin is absolutely detrimental for the stomach and duodenal mucosal surface and may cause ulcers or prevent lesions from healing. The same applies for smoking.
In cases like this the first thought goes to a duodenal ulcer which can be confirmed by endoscopy. Checking for Helicobacter pylori infection can be done at the same time. Biopsies can be taken from potentially suspicious areas.
If the upper gastrointestinal system has no visible lesion then checking the gallbladder is also warranted because (although not typical) it may cause similar symptoms. The easiest way to do that is with an ultrasound scan and perhaps blood tests.
Contact me again, for any further questions, you may have.
Kind Regards!
Needs investigation
Detailed Answer:
Hello,
the symptoms may point to duodenal ulcer (relief after eating, night symptoms, bacterial infection in the stomach etc). Zantac should have helped him. Motrin is absolutely detrimental for the stomach and duodenal mucosal surface and may cause ulcers or prevent lesions from healing. The same applies for smoking.
In cases like this the first thought goes to a duodenal ulcer which can be confirmed by endoscopy. Checking for Helicobacter pylori infection can be done at the same time. Biopsies can be taken from potentially suspicious areas.
If the upper gastrointestinal system has no visible lesion then checking the gallbladder is also warranted because (although not typical) it may cause similar symptoms. The easiest way to do that is with an ultrasound scan and perhaps blood tests.
Contact me again, for any further questions, you may have.
Kind Regards!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
So, is this case more along the lines of PUD possibly related to h.pylori rather than GERD? And, best treatment would be PPI?
Brief Answer:
Peptic ulcer
Detailed Answer:
Peptic ulcer is the most likely diagnosis. The most likely site of the ulcer is the duodenum because stomach ulcer usually cause pain right after the meals.
If no Helicobacter infection can be diagnosed then PPIs have to be used.
If Helicobacter infection is diagnosed then eradication treatment is given (which includes PPI).
Kind Regards!
Peptic ulcer
Detailed Answer:
Peptic ulcer is the most likely diagnosis. The most likely site of the ulcer is the duodenum because stomach ulcer usually cause pain right after the meals.
If no Helicobacter infection can be diagnosed then PPIs have to be used.
If Helicobacter infection is diagnosed then eradication treatment is given (which includes PPI).
Kind Regards!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Great!
For treatment of H. Pylori which would be the best regiment clarithromycin,
amoxicillin or metronidazole with the PPI and Is there a better PPI than another in this case?
For treatment of H. Pylori which would be the best regiment clarithromycin,
amoxicillin or metronidazole with the PPI and Is there a better PPI than another in this case?
Brief Answer:
I'll suggest other regimens
Detailed Answer:
Treatment with amoxicillin, clarithromycin and PPI may have a 20% failure rate in some areas.
The most efficient treatment is Bismuth salicylate, Metronidazole, Tetracycline and PPI (omeprazole or rabeprazole but any prazole can be used although some may not be officially FDA approved for this use).
The recommended first treatment includes amoxicillin and rabeprazole for 5 days and then rabeprazole, clarithromycin and tinidazole for another 5 days.
Kind Regards!
I'll suggest other regimens
Detailed Answer:
Treatment with amoxicillin, clarithromycin and PPI may have a 20% failure rate in some areas.
The most efficient treatment is Bismuth salicylate, Metronidazole, Tetracycline and PPI (omeprazole or rabeprazole but any prazole can be used although some may not be officially FDA approved for this use).
The recommended first treatment includes amoxicillin and rabeprazole for 5 days and then rabeprazole, clarithromycin and tinidazole for another 5 days.
Kind Regards!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Okay, great! What would the dose be? Do you start out low or high to attack it from the start?
Brief Answer:
The doses are mentioned in the full answer
Detailed Answer:
Rabeprazole 20mg bid, amoxicillin 1gr bid for 5 days and then
rabeprazole 20mg bid, clarithromycin 500mg bid, tinidazole 500mg bid for another 5 days.
BMT treatment lasts for 10-14 days and consists of:
bismuth 2 tablets qid, tetracycline 500mg qid, metronidazole 500mg tid and omeprazole 20mg bid.
Kind Regards!
The doses are mentioned in the full answer
Detailed Answer:
Rabeprazole 20mg bid, amoxicillin 1gr bid for 5 days and then
rabeprazole 20mg bid, clarithromycin 500mg bid, tinidazole 500mg bid for another 5 days.
BMT treatment lasts for 10-14 days and consists of:
bismuth 2 tablets qid, tetracycline 500mg qid, metronidazole 500mg tid and omeprazole 20mg bid.
Kind Regards!
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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