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A 52 year old man presents to the office for a routine physical. The review of symptoms reveals anorexia, heartburn, and weight loss over the past 6 months. The heartburn is long standing, occurring most days during the week. He takes TUMS or Rolaides to relieve the discomfort. The patient describes occasional use of ibuprofen for back pain, but denies other medications including herbals. He has no known allergies. He was adopted so does not know his family history. Social history reveals that, although he stopped smoking ten years ago, he smoked for 20 years. He occasionally consumes alcohol on the weekends only. The only positive physical exam finding for this patient was slight epigastric tenderness. The remainder of his exam was negative and the rectal exam was negative for blood.
The most common differential diagnosis for this patient based on history and examination are:
Erosive and hemorrhagic gastropathy
H.Pylori associated gastritis
Gastroesophageal reflux disease (GERD)
Erosive gastritis is commonly present in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) over a long period of time and who consumes alcohol (Papadakis and McPhee, 2015, p. 604). This condition is generally asymptomatic with little or no bleeding and causes significant epigastric pain associated with nausea, anorexia and vomiting. NSAIDs are proven to cause gastric irritation leading to erosive gastritis, nausea, vomiting and sometimes even ulceration and bleeding. (Katzung, Masters and Trevor, 2012, p. 635)
Gastric adenocarcinoma is also one of the possibilities in this case. Patient typically has favourable age and patients with history of smoking and long standing gastritis are more prone to develop gastric carcinoma (Kumar, Abbas and Aster, 2015, p. 771). The mean age of presentation is 55 years with male twice as much higher risk as females. It may present as epigastric tenderness due to contiguous effects on the adnexal structures. Patient also complains of weight loss which is pointing towards a malignant process occurring in the body.
H.Pylori gastritis is a non-erosive gastritis which is caused by spiral gram-negative bacteria called Helicobacter Pylori. It causes mucosal inflammation and infiltration with polymorphonuclear neutrophils (PMNs) and lymphocytes. It also presents with nausea and abdominal pain lasting several days. In chronic cases, the patients usually remain asymptomatic.
Gastroesophageal reflux disease (GERD) is most common in patients with age 40 and above. The most commonly occurring symptoms are heart burn, dysphagia, water brash, and continuous or frequent belching and retching. It occurs because of transient relaxation of lower esophageal sphincter during peristalsis leading to regurgitation of food content into the esophagus. GERD, if persists for longer periods, may lead to Barret’s esophagus which is the epithelial metaplasia. It is a pre-malignant condition.
DIAGNOSIS & TREATMENT:
In order to reach to a diagnosis, a series of test has to be done starting with non-invasive serologic testing. Later, more invasive and high yield testing modalities can be preferred like endoscopy with gastric mucosa biopsy, CT scanning or exploratory laparotomy in very rare cases. While the investigations are underway, a proton pump inhibitor (PPI) like omeprazole can be given with or without a gastroprokinetic like itropride to decrease the gastric acid production and transit time in the stomach. Both these things will significantly decrease the heart burn. An anti-emetic anti-nauseous drug like domeperidone can be administered to reduce nausea.
NSAID induced gastropathy has become utterly common owing to easy over the counter availability of NSAIDs. Proper diagnosis and differentiation from other medical entities is pivotal. Once the diagnosis is made, initiation of relevant and appropriate treatment should take place with cessation of inciting factor i.e., NSAIDs ingestion.
Katzung, B., Masters, S., & Trevor, A. (2012). Basic & clinical pharmacology. New York: McGraw-Hill Medical.
Kumar, V., Abbas, A.K., and Aster, J.C. (2015). Pathologic basis of disease. Philadelphia, PA: Saunders Elsevier.
Papadakis, M., & McPhee, S. (2015). Current Medical Diagnosis & Treatment 2015 (54th ed.). New York: McGraw-Hill Education/Medical.