Case

A 42-year-old complains of abdominal pain that began intermittently about 6 months in the upper left quadrant.  Recently the pain has become low level constant in nature, with enhancement of the pain shortly after meals including a sharper mid left back pain most recently.  They also report heartburn that has been occurring during the previous year which is also more prominent shortly after meals now.  The patient has been self-medicating with over-the-counter antacids, which have been providing some relief. They states his stools have changed in color over the previous month and now are intermittently dark and tarry in consistency. Tests of the patient’s stool finds occult blood (‘occult blood’ is blood that is not visible to the naked eye). 

Question 2/3 - What tests would you order to support or rule out your initial diagnosis?

Click on your selected option(s) below  (correct = 1, possible = 2, over-thinking = 3+)

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Incorrect. X-ray plain films are poor at soft tissue demarcation, particularly in complex areas such as the abdomen. Thus, this would not be a good initial tool to detect gastroesophageal reflux disease or peptic ulcers.

Incorrect. While CT scans have more resolution than a plain film x-ray, they are still weak at soft tissue demarcation and would not be able to readily detect gastroesophageal reflux disease or peptic ulcers.

Incorrect. MRI can be useful for detecting complications of gastroesophageal reflux disease or peptic ulcers, but is not the preferred test for the initial diagnosis.

Possible, but not the primary tool. Ultrasound can play a role in diagnosis of peptic ulcers, but is not the primary initial test. It is usually utilized in situations where the patient may not be able to tolerate the primary method or has contraindications for the primary method.

On ultrasound you are looking for characteristic ulcer features such as hypoechogenic areas (darkening) and thickened or edematous regions of the stomach/duodenum wall.

Correct!  Upper endoscopy is the primary tool to determine if the patient has peptic ulcer disease or gastroesophageal reflux disease causing injury to the region.

Other imaging modalities can play a secondary role if endoscopy cannot be tolerated or is contraindicated (e.g. children or pregnant women).

Incorrect. A surgical exploration of the abdomen is quite invasive and would not be a good initial screening method for ulcers or GERD.