Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 35-year-old man is evaluated for a 2-month history of upper abdominal discomfort after eating. He has recently returned from working in a rural area of a developing country. He takes no medications. There is no family history of esophageal or gastric cancer.

On physical examination, vital signs are normal. BMI is 40. Centripetal obesity is noted, but abdominal examination findings are otherwise normal.

Laboratory studies reveal a hemoglobin level of 15 g/dL (150 g/L).

Which of the following is the most appropriate management?

A. Barium esophagogram
B. Empiric Helicobacter pylori eradication therapy
C. H. pylori testing
D. Upper endoscopy

MKSAP Answer and Critique

The correct answer is C. H. pylori testing.

The most appropriate management is noninvasive Helicobacter pyloritesting, followed by eradication therapy if test results are positive. Noninvasive H. pylori testing modalities include serology, the fecal antigen test, or the urea breath test. The recommended and most cost-effective approach for this patient is serologic testing. He is younger than 50 years of age with vague abdominal discomfort without alarm features (anemia; dysphagia; odynophagia; vomiting; weight loss; family history of upper gastrointestinal malignancy; personal history of peptic ulcer disease, gastric surgery, or gastrointestinal malignancy; and abdominal mass or lymphadenopathy on examination), and, most importantly, he has been residing in an area where the prevalence of H. pylori is high (a developing country). Serologic testing for H. pylori has limitations in that it does not test for active H. pylori infection and has poor positive predictive value. Therefore, positive serologic results must be interpreted with caution when performed in populations with a low background prevalence of H. pylori, such as those in developed countries. Fecal antigen testing and urea breath testing offer a more accurate means of noninvasive testing for H. pylori, as both of these test modalities assess for the presence of active infection. Therefore, these testing modalities should be used to test for H. pylori in individuals for whom the background prevalence of H. pylori is low. Although these tests are more expensive and logistically more complicated than serology, they offer greater testing accuracy. Fecal antigen and urea breath tests are equivalent in terms of their accuracy. The choice of fecal antigen testing versus urea breath testing will typically depend on test availability and patient preference.

A barium esophagogram would have limited utility in this patient with dyspepsia and no associated symptoms consistent with esophageal disease, such as acid brash, dysphagia, and odynophagia. Even with these symptoms, an empiric trial of a proton pump inhibitor (PPI) could be considered prior to imaging with a barium esophagogram.

Empiric treatment for H. pylori is not appropriate because the diagnosis of H. pylori should be made before initiating treatment. Empiric therapy for H. pylori is expensive and carries the potential harm of medication side effects; therefore, it would not be indicated without first confirming active infection.

Upper endoscopy would be appropriate for patients whose symptoms do not respond to H. pylori treatment or PPI therapy. Patients older than 50 years or with alarm features should be evaluated with upper endoscopy. In patients without alarm features, endoscopy as an initial management intervention would be unlikely to find gastritis, peptic ulcer disease, or esophagitis.

Key Point

• Before pursuing Helicobacter pylori eradication therapy, noninvasive testing for H. pylori should be performed to confirm infection.

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