Managing Abdominal Pain and Back Pain in a Patient with Possible Peptic Ulcer Disease and Back Strain

QUESTION

Douglas Kelly, a 46 yo male comes in to the clinic complaining of Abdominal pain with occasional nausea. He has a history of Back pain & GERD that is well controlled with OTC ibuprofen & Rolaids. His abdominal pain has been getting more frequent, almost daily, & more intense. It comes on about 2 hrs after eating & radiates to his back. He has been under a lot of stress lately at work & has not been watching his diet closely, & drinking 4 cups of coffee to stay awake since he hasn’t been sleeping as well due to the pain. He works for UPS where he does lots of lifting & bending that aggravates his back pain. His exam is unremarkable except for epigastric tenderness & back pain with movement. You suspect he has a back strain & PUD.

1) How would you treat this patients PUD as a 1st , 2nd, 3rd line agent based on guidelines?

2) Are there any labs you’d like to order to make a diagnosis, rule out sequelae, & other etiologies of PUD?

3) How would you treat this patients back pain using 1st 2nd, 3rd line agents?

4) Are there any labs or studies you might consider before ordering medication to treat his back pain.

ANSWER

Managing Abdominal Pain and Back Pain in a Patient with Possible Peptic Ulcer Disease and Back Strain

Introduction

Douglas Kelly, a 46-year-old male, presents with abdominal pain and occasional nausea, along with a history of back pain and gastroesophageal reflux disease (GERD). This case study highlights the need to address both potential peptic ulcer disease (PUD) and back strain. In this essay, we will discuss the treatment options for PUD based on guidelines, identify relevant labs for diagnosis and ruling out other etiologies, and explore the management of back pain, considering various lines of treatment and the necessity of additional labs or studies.

Treating Peptic Ulcer Disease (PUD)

Based on guidelines, the treatment of PUD involves a stepwise approach:

First-Line Agent: Proton Pump Inhibitors (PPIs) such as omeprazole or lansoprazole are the recommended first-line agents for PUD. These medications reduce gastric acid secretion, promoting ulcer healing and symptom relief.

Second-Line Agent: If symptoms persist or if there is concern about clarithromycin resistance, a second-line agent such as H2 receptor antagonists (e.g., ranitidine) or bismuth quadruple therapy (e.g., bismuth subsalicylate, metronidazole, tetracycline, and PPI) may be considered.

Third-Line Agent: In cases of treatment failure with PPI-based therapies, consultation with a gastroenterologist is recommended to explore further options such as high-dose PPI therapy or combination regimens.

Diagnostic Labs for PUD

To confirm the diagnosis of PUD, rule out complications, and identify other etiologies, the following labs may be ordered:

– Helicobacter pylori (H. pylori) testing: H. pylori infection is a common cause of PUD. Testing can include serology, stool antigen, or urea breath test.
– Complete blood count (CBC): To assess for anemia or signs of infection.
– Liver function tests (LFTs): To evaluate liver health and rule out liver-related causes of abdominal pain.
– Amylase and lipase: To rule out pancreatitis as a potential cause of abdominal pain.

Treating Back Pain

Considering Douglas’ occupation involving lifting and bending, management of his back pain should focus on pain relief and functional improvement:

First-Line Agents: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can provide initial pain relief. Topical analgesics or heat/cold therapy may also be considered.

Second-Line Agents: If NSAIDs are contraindicated or ineffective, muscle relaxants such as cyclobenzaprine or opioids may be used for short-term pain relief. However, caution should be exercised due to their potential side effects and risk of dependency.

Third-Line Agents: In cases of persistent or chronic back pain, referral to a specialist for further evaluation and consideration of interventions like physical therapy, spinal manipulation, or epidural steroid injections may be necessary.

Labs or Studies for Back Pain

Before initiating medication for back pain, considering the physical nature of Douglas’ job and the need to rule out underlying conditions, the following labs or studies may be considered:

– Imaging studies: X-rays or MRI of the spine can help identify structural abnormalities, disc herniation, or nerve impingement that may contribute to back pain.
– Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP): To assess for signs of inflammation or infection that could be contributing to the back pain.

Conclusion

Managing Douglas Kelly’s abdominal pain suggestive of PUD and his backpain requires a comprehensive approach. Treatment for PUD should follow guideline recommendations, including the use of PPIs as first-line agents. Diagnostic labs can help confirm the PUD diagnosis and rule out other etiologies. For back pain, initial management involves NSAIDs or other analgesics, with referral to a specialist if needed. Consideration of labs and imaging studies can help evaluate the underlying causes of back pain and guide appropriate treatment decisions. Collaborative and patient-centered care is essential to ensure optimal outcomes for Douglas in managing both PUD and back strain.