A 63 Year Old Man Presents With The complains Of Burning Epigastric pain

A 63 year old man presents to his primary care physician with the complaint of burning epigastric pain that occurs soon after eating. He says the pain begins within an hour after taking the meals and also describes having mild nausea associated with the pain. He says that these symptoms have begin about 2 months back and in the last week he had an episode of vomiting and he noticed some brown discoloration in his vomitus. He denies having any blood in the stool or any history of weight loss.
He gets some pain releif by over the counter antacids and ranitidine.
Past History: His past history is significant for osteoarthritis in both his knees and he has been taking naproxen and asprin for the pain relief.
On examination there was mild tenderness on palpation in the epigastric area otherwise no other abnormality was detected.

What is the Differential Diagnosis on the basis of above given history and examination?

Differential Diagnosis:

• Gastritis
• Peptic ulcer disease
• Zollinger Ellison syndrome
• Pancreatitis
• Gastro esophageal reflux disease
• Gastric cancer

The patient was referred for an esophago-gastro-dudenoscopy and has following picture seen:

An ulcer was seen on the lesser curvature of the stomach. 

Diagnosis: Gastric ulcer (peptic ulcer disease) secondary to NSAID overuse.

Case Discussion:

Peptic Ulcer Disease:

• Erosion of the gastric or duodenal mucosal surface secondary to impaired endothelial protection and increased gastric acidity. 
• Duodenal ulcers are more common and are most often a result of H.Pylori infection.
• Gastric ulcers are less common and are commonly due to NSAID over use. 
• Patients usually present with a history of burning epigastric pain that may vary in intensity, sometimes nausea, hematemesis or melena.
• On examination there may be mild tenderness in the epigastric region but if the ulcer has perforated then there is abdominal rigidity and rebound tenderness.
• Diagnosis is mainly done clinically.
• EGD is usually performed to visualize the ulcer, ascesss bleeding and to perform biopsy so as to rule out cancer. 
• Treatment with proton pump inhibitors and H2 receptor antagonists which help in decreasing the gastric acid levels and prevent further mucosal damage. 
• Other drugs like sucralfate, bismith subsalicylate and misoprostol may be useful to aid in mucosal protection.