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Urease breath test
56%
235/417
Empiric proton pump inhibitor therapy
11%
45/417
Upper endoscopy with biopsy of gastric mucosa
24%
102/417
Esophageal pH monitoring
2%
9/417
Barium swallow
7/417
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This patient likely has dyspepsia due to peptic ulcer disease. Given that the patient denies heartburn symptoms, H. pylori testing should be conducted (urease breath test or stool antigen testing). H. pylori is a Gram-negative bacillus and a facultative anaerobe. It is catalase-positive, oxidase-positive, and urease-positive. The organism is very strongly linked with duodenal ulcers (it may be responsible for up to 90% of cases). H. pylori is also a common cause of gastric ulcers and gastritis. It is associated with gastric cancers, especially adenocarcinoma and gastric lymphoma. In the stomach, the most commonly affected areas are near the pylorus and along the lesser curvature. Fashner et al. discuss the diagnosis of H. pylori-induced peptic ulcer disease (PUD). In the absence of chronic NSAID use, H. pylori is the most likely cause of PUD. In patients over the age of 55, or in patients who display alarm symptoms such as bleeding, anemia, or weight loss, or with family history of gastric malignancy, upper endoscopy should be used to rule out malignancy. However, absent these conditions, the urease breath test is recommended for use with a test-and-treat strategy. Graham discusses the treatment of H. pylori. The overall strategy involves making a diagnosis, treating, and repeating testing to confirm eradication after treatment. Treatment strategies generally incorporate "triple therapy," which includes two antibiotic medications and an antacid medication. Metronidazole and clarithromycin are two commonly used antibiotics (however, resistance to clarithromycin is reported to be increasing). Illustration A from the National Science Foundation (NSF) depicts the pathogenic mechanism of H. pylori induced ulcers. Illustration B shows the algorithm for management of uninvestigated dyspepsia from the American College of Gastroenterology. Incorrect Answers: Answer 2: Empiric proton pump inhibitor therapy is inappropriate and insufficient to eradicate likely H. pylori infection. Answer 3: Upper GI endoscopy is not recommended as the first diagnostic intervention in a patient under the age of 55 without alarm symptoms. Answer 4: Esophageal pH monitoring can be used in the diagnosis of GERD, not H. pylori induced peptic ulcers. Answer 5: Barium swallow is not useful in diagnosing H. pylori infection.
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