HY USMLEQ#14 Gastroenterology Step 2CK
Level Step 2 CK/3 (inspired by step 3 UWorld)
A 39-year-old man is diagnosed with Helicobacter pylori, but there is no evidence of malignancy. He is given triple therapy: Clarithromycin, Amoxicillin, and Pantoprazole. He reports that he initially felt better, but he had intermittent recurrence of the abdominal pain after a month of starting the treatment. He experiences occasional nausea; however, there is no vomiting, hematemesis, or melena. What is the best next step in the management of this patient?
A. Stool testing for helicobacter pylori antigen
B. Refer to a surgeon
C. Repeat treatment with pantoprazole and 2 antibiotics
D. Repated upper gastrointestinal endoscopy
E. Treat with a different proton pump inhibitor
✅ Correct answer = Choice A. Stool testing for helicobacter pylori antigen
Education Objective:
Common methods for determining bacterial eradication include the urea breath test and fecal antigen testing. Testing should occur more than 4 weeks after completion of the therapy. If testing confirms eradication but symptoms remain, other etiologies should also be considered. In patients who do not clear the infection after first-line treatment, second-line options are available.
❌ Choice B. No, there are antibiotics, there is acid suppression therapy for Peptic ulcer disease, and surgery is only performed for complications such as perforation and refractory hemorrhage. We would only consider surgery if there is failure of antibiotic therapy.
❌ Choice C. Re-treating the patient without testing for eradication is inappropriate, as we could easily evaluate the presence of Helicobacter Pylori and the need to consider a different diagnosis in the setting of persistent symptoms.
❌ Choice D. Repeat upper endoscopy can help establish that Helicobacter pylori has been eradicated; however, given the availability of less invasive options ( for example, urea breath test ), it should be reserved for patients with indeterminate indirect testing or if there are other indications for endoscopy.
❌ Choice E. Simply switching to a different proton pump inhibitor is an insufficient strategy due to the risk of treatment failure and antibiotic resistance.