4.

Сlinical case
A 30-year-old patient came to the rural primary care clinic (СВП) complaining of heartburn and
pain along the midline between the xiphoid process and the umbilicus, characterized by
periodicity, seasonality, relief after vomiting, and weakness. The patient says that these
complaints have bothered him since age 7. Harmful habits: he smokes, likes large amounts of
acidic and salty foods. On exam: Overall condition is relatively satisfactory; the skin and visible
mucous membranes are pale; tongue is coated. Palpation reveals epigastric tenderness. BP
120/80 mmHg, pulse 76 per minute.
Questions/Answers
(Points)
1. Which diseases are characterized by these signs?
2. Which questions would you ask to clarify the diagnosis?
o What will the examination and assessment consist of?
3. Your diagnosis?
4. Your management plan? Identify the laboratory and instrumental investigation
methods
5. Determine further treatment for the patient. Prevention and follow-up (dispensary
observation) for the disease

Ans. Below is a detailed, step‐by‐step approach to the case:

1. Differential Diagnosis: Diseases with These Signs

The patient’s long-standing history (since age 7) of heartburn and midline epigastric pain—with
periodic, seasonal exacerbations, relief after vomiting, and associated weakness—can be seen in
several conditions, including:

• Chronic Gastritis (often related to Helicobacter pylori infection or chemical irritation)

• Peptic Ulcer Disease (PUD), especially a duodenal ulcer (classically with pain relief after
vomiting)

• Functional (Non-ulcer) Dyspepsia (a functional gastrointestinal disorder with similar

• Gastroesophageal Reflux Disease (GERD) (though GERD often has a more prominent burning
retrosternal pain, it may overlap)

• Bile Reflux Gastritis (which can also cause epigastric discomfort)

History (Questions to Ask):

• Pain Characteristics:

• How long does each episode last?

• Is the pain burning, gnawing, or dull?

• What is the precise timing of pain in relation to meals (before, during, or after eating)?

• Does the pain occur at night or early in the morning?

• Associated Symptoms:

• Do you experience nausea, vomiting (and how often)?

• Is there any weight loss, early satiety, or changes in bowel habits?

• Do you notice any blood in vomitus or stools (black, tarry stools)?

• How frequent is the heartburn and is it triggered by specific foods or positions?

• Past Medical and Family History:

• Any previous diagnosis or treatment for gastrointestinal diseases?

• Family history of peptic ulcer disease or gastrointestinal cancers?

• Lifestyle and Dietary Habits:

• Details on smoking habits, alcohol intake, and consumption of spicy, acidic, or salty foods

• Use of over-the-counter medications (especially NSAIDs) that could affect the stomach lining

Physical Examination and Assessment:

• General Appearance:

• Look for signs of chronic illness such as pallor (which may indicate anemia from chronic blood
loss).
• Abdominal Examination:

• Palpate the epigastrium for tenderness, guarding, or masses

• Assess for hepatosplenomegaly, which might suggest other gastrointestinal or systemic

• Other Systemic Signs:

• Examination of the tongue and mucous membranes (noting coating or pallor)

• Vital signs (already within normal limits here)

3. Likely Diagnosis

Based on the history and examination, the most likely diagnosis is:

Chronic Gastritis (with a possible underlying H. pylori etiology)

– In some cases, features may overlap with Peptic Ulcer Disease (particularly duodenal ulcer),
given the relief with vomiting and the long duration of symptoms.

4. Management Plan and Recommended Investigations

Laboratory Studies

1. Complete Blood Count (CBC):

• To evaluate for anemia (low hemoglobin/pallor may indicate chronic blood loss).

2. H. pylori Testing:

• Non-invasive methods:

• Urea Breath Test (preferred for active infection)

• Stool Antigen Test

• Serological Testing (may indicate past exposure but less reliable for active infection)
3. Biochemistry Panel:

• Liver and kidney function tests to rule out other causes of dyspepsia and for baseline
assessment before therapy.

4. Iron Studies:

• If anemia is present, to evaluate for iron deficiency.

Instrumental Studies

1. Esophagogastroduodenoscopy (EGD):

• Indications:

• Direct visualization of the gastric mucosa

• Identification of erosions, ulcerations, or signs of atrophic gastritis

• Biopsy for histopathological examination and H. pylori testing (rapid urease test, histology)

2. Abdominal Ultrasound:

• Can be considered if there’s suspicion of biliary pathology or to assess other upper abdominal
organs.

3. Barium Studies (Upper GI Series):

• An alternative when EGD is unavailable or contraindicated, though less sensitive for mucosal
lesions.

5. Treatment, Prevention, and Follow-Up

A. Non-Medicinal (Lifestyle and Dietary Modifications)

• Dietary Changes:

• Reduce or avoid spicy, acidic, and salty foods, as well as carbonated beverages.

• Eat small, frequent meals instead of large meals.

• Avoid eating late at night.

• Smoking cessation is strongly recommended, as smoking worsens gastritis and peptic ulcer
disease.

• Reduce or eliminate the use of “tea soda” (baking soda) as its temporary neutralizing effect can
lead to rebound acid secretion.

• Stress Management:

• Advise on relaxation techniques or stress reduction strategies if stress is a contributing factor.

B. Medicinal Treatment

• If H. pylori is detected:

• Triple Therapy:

• Proton Pump Inhibitor (PPI): e.g., Omeprazole 20 mg once daily (before breakfast)

• Clarithromycin: 500 mg twice daily

• Amoxicillin: 1 g twice daily (or metronidazole 500 mg twice daily if allergic to penicillin)

• Duration: Typically 10–14 days.

• If H. pylori is not detected or after eradication:

• Acid Suppression:

• PPI: Continue Omeprazole or another PPI for 4–8 weeks to promote mucosal healing.

• Antacids/Alginate Therapy:

• Use as needed for symptomatic relief.

• Mucosal Protectants:

• Sucralfate may be considered if there are ulcerative lesions.

C. Prevention and Dispensary (Follow-Up) Measures

• Inform about dietary triggers and the importance of avoiding smoking and irritants.

• Stress the need for adherence to treatment, especially if H. pylori is detected.

• Regular Follow-Up:

• Schedule a re-evaluation 4–8 weeks after initiating therapy to assess symptom resolution and
treatment compliance.

• If symptoms persist or recur, consider repeating endoscopy or additional H. pylori testing.

• Long-Term Monitoring:

• For patients with chronic gastritis, periodic endoscopic surveillance may be indicated,
especially if there are risk factors for complications (e.g., atrophic gastritis, intestinal
metaplasia).

• Lifestyle Support:

• Consider referral for smoking cessation programs or nutritional counseling.

This structured approach ensures that all aspects of diagnosis, investigation, and management are
addressed for a patient with long-standing dyspeptic complaints.