Abdominal Pain OSCE - Peptic Ulcer Disease

Case Overview

• Age/Sex: 53-year-old male
• Occupation: Accountant (sedentary office job)
• Setting: Primary care / urgent clinic
• Chief complaint: "Abdominal pain"

Patient Script

Who I Am

I'm 53, I work as an accountant and I sit at a desk most of the day.

What Brings Me In

I've had this burning pain in the upper part of my tummy for a few weeks and it's not going away.

My Story

It started about 3 weeks ago as a mild burning sensation just above my belly button and under my ribs. At first it came after I ate very spicy food, but for the last 2 weeks it's more or less there every day. The pain is worst about 2–3 hours after eating and often wakes me at night, but if I eat something or take an antacid I usually feel better. I've been taking some over-the-counter antacids with partial relief and once bought an omeprazole online for a couple of days which helped a bit. I have lost about 3 kg over the 3 weeks because I haven't been eating as much.

I've also had one episode of a tight feeling in my chest when I was very stressed at work a few weeks ago — it only lasted a few minutes and went away. I sometimes take ibuprofen for a sore back (about 400 mg, three times a week). I smoke about 20 cigarettes a day and usually have 2 beers most evenings. A friend gave me some travel tablets recently and I had one dark-looking stool the next day — I thought it might be from that.

My Medical Background

• Past medical history: hypertension diagnosed 2 years ago (well controlled)
• Current medications: lisinopril 10 mg once daily, occasional ibuprofen 400 mg PRN
• Allergies: none known
• Social: smokes 20 cigarettes/day, drinks 2 beers most evenings, sedentary job, lives with wife
• Family: father died of a heart attack at 70; mother has type 2 diabetes

What I Think & Worry About

• I think it might be something I ate or an ulcer — I'm worried it could be something serious like stomach cancer or maybe my heart because of that tightness I had once.
• I'm worried it won't get better and I might need tests or time off work.

If You Ask Me About Other Symptoms...

• Appetite: "A bit less than usual — I'm avoiding big meals because it hurts."
• Vomiting: "No vomiting."
• Blood in vomit/stool: "No vomiting blood. I had one black-ish stool after those travel tablets, but I haven't seen blood."
• Bowel habit: "Mostly normal, maybe a bit constipated sometimes."
• Heart symptoms: "Just that one tight spell when stressed — it passed quickly and I felt fine."
• Fever/night sweats: "No fevers, but I do wake with pain at night sometimes."
• Medication use: "I sometimes take ibuprofen for my back — maybe three times a week."

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Clinical Summary

Examination

• General: alert, comfortable at rest, appears mildly anxious
• Vital signs: temperature 36.8°C, heart rate 78 bpm, blood pressure 138/86 mmHg, respiratory rate 14/min, SpO2 98% on air
• Weight: 82 kg (patient reports ~85 kg 3 weeks ago)
• Cardiorespiratory exam: heart sounds normal, clear lungs, no chest wall tenderness
• Abdominal exam: soft, no distension, mild tenderness localized to the epigastrium on light palpation, no guarding or rebound, bowel sounds present
• Rectal exam: stool visible, brown; fecal occult blood test negative at bedside

Investigations

• Full blood count: Hb 13.5 g/dL, WCC 7.8 x10^9/L, platelets 250 x10^9/L (no anemia, no leukocytosis)
• Urea & electrolytes: Na 139 mmol/L, K 4.1 mmol/L, creatinine 88 µmol/L, urea 5.2 mmol/L (renal function preserved)
• Liver function tests: ALT 28 IU/L, ALP 78 IU/L, bilirubin 10 µmol/L (within reference ranges)
• CRP: 2 mg/L (not elevated)
• ECG: sinus rhythm, no ischemic changes (to evaluate chest tightness)
• H. pylori stool antigen: positive (indicates active H. pylori infection)
• Fecal occult blood (laboratory): negative (no evidence of ongoing GI bleeding)
• Upper GI endoscopy (esophagogastroduodenoscopy), if performed: 1 cm duodenal ulcer on the anterior bulb with clean base, no active bleeding, biopsy/cytology not suspicious for malignancy

Diagnosis

• Primary diagnosis: Peptic ulcer disease — likely duodenal ulcer due to H. pylori infection

  • Supporting evidence: classical history of epigastric burning pain, pain 2–3 hours after eating and nocturnal pain, partial relief with food/antacids, positive H. pylori stool antigen, localized epigastric tenderness, endoscopy (if done) showing duodenal ulcer with clean base.

• Differential diagnoses:

  • Gastritis (would give epigastric discomfort but pain pattern with meals and positive H. pylori point to peptic ulcer)
  • Gastro-oesophageal reflux disease (GERD) — typically worse on lying down and after meals, often with heartburn/acid regurgitation; less likely given nocturnal pain relieved by eating and duodenal ulcer features
  • Biliary colic/cholelithiasis — pain is usually right upper quadrant and post-prandial fatty-food related; exam lacks Murphy's sign
  • Peptic ulcer disease related to NSAID use — possible contributor (occasional ibuprofen) but H. pylori positivity and classic timing favour duodenal ulcer from H. pylori
  • Pancreatitis — severe steady epigastric pain radiating to the back with elevated amylase/lipase; not supported by presentation or labs
  • Cardiac chest pain — considered due to reported tightness but ECG normal and pain is abdominal with clear temporal relation to meals

Management

• Acute management and symptom relief:

  • Start a proton pump inhibitor (e.g., omeprazole 20–40 mg once daily) immediately for symptomatic relief and to promote ulcer healing.
  • Advise stopping NSAIDs (avoid ibuprofen) and advise on safe alternatives for pain (paracetamol as first-line).
  • Strongly advise smoking cessation and reduction of alcohol intake; refer to smoking cessation services.

• H. pylori eradication:

  • Start first-line eradication therapy (example depending on local resistance patterns): PPI + amoxicillin 1 g BID + clarithromycin 500 mg BID for 14 days.
  • If penicillin allergic or local clarithromycin resistance high, use an alternative regimen (e.g., PPI + bismuth quadruple therapy or PPI + metronidazole + tetracycline regimen as per local guidelines).
  • Inform patient to complete the full course and potential side effects (GI upset, metallic taste, etc.).

• Follow-up and safety-netting:

  • Arrange review in 2–4 weeks to assess symptom response.
  • If symptoms persist despite therapy, if alarm symptoms develop (progressive weight loss, persistent vomiting, GI bleeding, dysphagia, anemia), or if patient fails eradication, arrange upper GI endoscopy (if not already performed) and biopsy as indicated.
  • Test eradication 4–8 weeks after completion of therapy using a urea breath test or stool antigen test; ensure patient has stopped PPI for at least 2 weeks before testing to avoid false negatives.

• Additional measures:

  • Consider short-term antacid or alginate for symptomatic relief as needed.
  • Review cardiovascular risk given smoking and hypertension; manage per guidelines but not the primary issue here.

Key Learning Points

• Timing of epigastric pain relative to meals helps distinguish duodenal (pain occurs several hours after meals and at night, often relieved by food) from gastric ulcers (pain often worse with eating).
• In patients under ~55 without alarm features, a test-and-treat strategy for H. pylori is appropriate; positive H. pylori warrants eradication therapy plus a PPI.
• Ask about and stop contributing factors (NSAIDs, smoking); arrange endoscopy when alarm features are present or if symptoms do not respond to appropriate therapy.