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

A 55-year-old man is evaluated in the emergency department for a 2-day history of mild nausea and dyspepsia that is worse with fasting and improved with eating. He has also had a 24-hour history of frequent black stools and fatigue. He has no history of gastrointestinal bleeding, alcoholism, chronic liver disease, bleeding disorders, cardiovascular disease, or cancer.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 114/66 mm Hg, pulse rate is 85/min, and respiration rate is 14/min; BMI is 27. Abdominal examination reveals epigastric tenderness without guarding or rebound. Rectal examination identifies melena. Laboratory studies are normal except for a hemoglobin level of 7.9 g/dL (79 g/L). He is admitted to the hospital and is given intravenous fluid resuscitation and intravenous proton pump inhibitor (PPI) therapy.

Upper endoscopy identifies a 1-cm clean-based gastric ulcer.

Which of the following is the most appropriate next step in management?

A. Blood transfusion
B. Endoscopic treatment
C. Octreotide
D. Substitute oral for intravenous PPI

MKSAP Answer and Critique

The correct answer is D. Substitute oral for intravenous PPI.

The most appropriate next step in management is to switch the intravenous proton pump inhibitor (PPI) to an oral PPI because this patient’s low-risk ulcer does not require prolonged intravenous treatment or observation. Low-risk gastric ulcers are clean-based or have a nonprotuberant pigmented spot and should be treated with oral PPI therapy, initiation of refeeding within 24 hours, and early hospital discharge.

Blood transfusion should be performed in patients with (1) hemodynamic instability and ongoing bleeding or susceptibility to complications from oxygen deprivation (for example, ischemic heart disease) and (2) a hemoglobin level less than 7 g/dL (70 g/L) if hemodynamically stable with no active or massive bleeding. This patient does not meet these criteria.

Endoscopic treatment of the ulcer is not appropriate because clean-based ulcers are at low risk for rebleeding and the risks of endoscopic therapy outweigh any potential benefits in this patient.

Octreotide is not a routine treatment, even for acute active bleeding, unless variceal bleeding is suspected. This patient has a low-risk ulcer and no evidence of esophageal varices, so octreotide is not indicated.

Key Point

• Low-risk gastric ulcers are clean-based or have a nonprotuberant pigmented spot; they should be treated with oral proton pump inhibitor therapy, initiation of refeeding within 24 hours, and early hospital discharge.

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