hero
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35. A 42-year-old man has a 6-week history of epigastric pain following meals and at night. The patient does not smoke cigarettes but does drink alcoholic beverages socially. He denies use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin. Physical examination and routine laboratory studies are normal.
A proton pump inhibitor is begun. One week later, upper endoscopy is performed, which shows a small, clean-based ulcer in the duodenal bulb. Rapid urease testing of an endoscopic gastric antral biopsy specimen is negative.
Which of the following is the most likely cause of this patient’s ulcer?
A. Zollinger-Ellison syndrome
B. Helicobacter pylori infection
C. Duodenal adenocarcinoma
D. Alcohol consumption
E. Surreptitious NSAID use
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| gingko
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E..
ZE unlikely with a solitary ulcer and without ass. symptoms
urease on biopsy is negative(isnt this gold standard, if i remember correctly?)
duodenal cancer: hmm..but the clean base ulcer??
social alcohol also least likely
that leaves NSAIDs..they are known to be toxic even upto the colon, but would they cause isolated DU???i dont know
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| cool doctor
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E
as gingko, by exclusion
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| neurom
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B. Rapid urease test lacks sensitivity..
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| romano
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gingko wrote:
E..
ZE unlikely with a solitary ulcer and without ass. symptoms
urease on biopsy is negative(isnt this gold standard, if i remember correctly?)
duodenal cancer: hmm..but the clean base ulcer??
social alcohol also least likely
that leaves NSAIDs..they are known to be toxic even upto the colon, but would they cause isolated DU???i dont know
I agree with your thoughts, but I don't think E is very likely to be the answer either. There's nothing in the question suggesting NSAID use, like e.g headache, and if he indeed was using NSAIDs a DU is not the most likely location of an ulcer. Stomach is much more likely. If you think that he uses to much NSAID, he could just as likely drink to much alcohol without telling us.
I think I go with ZE instead. Not a very characteristic presentation, i agree, but it says in harrison that diarre etc isn't mandatory...
Though question...
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| gingko
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H pylori–negative duodenal ulcer
Virtually all non–H pylori-related duodenal ulcers were assumed to be secondary to NSAID use. However, these ulcers have received much attention recently, and some studies have shown that the proportion of H pylori–related duodenal ulcers is significantly less than the commonly reported 85-95%. One group examined 2400 endoscopically proven, non–NSAID-related duodenal ulcers and found that only 73% patients were positive for H pylori. However, other studies have produced conflicting results, and one study showed that antibiotic use within 1 month of diagnosis may have resulted in false-negative results.
Non–H pylori duodenal ulcers that are not related to NSAID use may be more common than previously appreciated. This observation supports the assertion that the acid hypersecretion and rapid gastric emptying observed in many patients
http://www.emedicine.com/med/topic591.htm
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| neurom
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It is still B.. Proton pump inhibitor will give rapid urease test negative result.
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| anastamosis
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A. unlikely to be ZES with just single ulcer.
B. ONLY ONE THAT IS LEFT !! 
C. No associated symphtoms, clean base ulcer
D. Social alcohol use
E. Paitent denies NSAID use
Proton pump inhibitors significantly reduce the sensitivity of urea breath tests and fecal antigen assays (but not serologic tests) and should be discontinued 7–14 days prior to testing.
In patients with active upper gastrointestinal bleeding or patients taking proton pump inhibitors, histologic assessment for H pylori is preferred. Histologic assessment of biopsies from the gastric antrum and body is more definitive but more expensive ($150–$250) than a rapid urease test. Histologic assessment is also indicated in patients with suspected MALTomas and, possibly, in patients with suspected infection whose rapid urease test is negative.
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| hero
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That's correct. All bcs of PPI 
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| Ivonne
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I agree that the rapid urease test RUT has the higher sensitivity and specificity and is less expensive but there are two things is this patient
1.-He has taken PPI for a week and it may alter the results
2.-If the patient said that he didn't take NSAIDs and ASA( I know, don't believe everyhting the patient said...) and doesn't have alarm symptoms i would think of H pilory as a first possibility.
In the RUT is negative and there is a high suspicion of H pylori infection, the second biopsy specimen then can be sent for histology
So I will go with B
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| sandra
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here the patients denies NSAID use. if the patient denies anything, the boards require u to believe him. period.
the biopsy specimen which is negative for urease test was taken from the gastric antrum. but the ulcer described is seen in the duodenal bulb. i think its h.pylori. what say?
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| anastamosis
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Biopises for h pylori are to be taken from ANTRUM and BODY of stomach
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| cool doctor
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but he took a bx from the ulcer, isnt this the best test for h.pyori?
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| neurom
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they took antral biopsy. It is supposed to be positive in H. pylori infection unless the pt takes proton pump inhibitors...
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