A 45 year old CEO presents to your clinic with complains of severe heartburn and upper abdominal pain that have been present for the past few weeks. Pain is slightly improved with OCT Prilosec and TUMS, and better with meals, but between meals pain is severe. Which diagnosis in your DDx is most likely?

A. Duodenal ulcer

B. GERD

C. Gastric ulcer

D. Esophageal stricture

E. Achalasia

 

Answer:

C. Duodenal ulcer

Step-by-step explanation

Duodenal ulcer is the primary impression since the patient is experiencing heartburn and constant, severe upper abdominal pain that is relieved with food intake. Pain associated with duodenal ulcer also recurs 2-3 hours after taking a meal as in the patient. Taking Prilosec or Omeprazole, a proton pump inhibitor as well as antacids such as TUMS, may also relieve the pain. Gastric ulcers may also present similarly however, the pain in gastric ulcers are usually worsened with meals unlike in the patient's case. GERD also presents with heartburn and burning upper abdominal pain. However, the pain is usually less severe and symptoms such as regurgitation, bad breath, and a metallic taste in the mouth is also present which was not the case in our patient. Achalasia is least likely because the patient did not have any dysphagia and regurgitation, the main symptoms of achalasia.

Reference:

Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.). New York: McGraw Hill Education.