Single Best Answer (SBA) · Peptic Ulceration and Helicobacter pylori
A 60-year-old man has had upper abdominal pain for 2 years with dyspeptic symptoms. He has chronic knee pain for which he takes regular NSAIDs. What is the most likely diagnosis?
Show answer and explanation
Answer: B. Peptic ulcer disease
NSAID-related peptic ulcer disease
Chronic epigastric/dyspeptic pain in a patient on regular NSAIDs is peptic ulcer disease until proven otherwise.
Why NSAIDs cause ulcers
- NSAIDs inhibit cyclo-oxygenase-1 (COX-1), reducing mucosal prostaglandin synthesis.
- Prostaglandins normally stimulate mucus and bicarbonate secretion and maintain mucosal blood flow.
- Loss of this protection tips the balance towards acid-peptic injury.
The acid-versus-defence balance
| Aggressive factors | Defensive factors |
|---|---|
| Acid and pepsin | Mucus and bicarbonate layer |
| H. pylori | Mucosal cells and trefoil peptides |
| NSAIDs, alcohol, smoking | High mucosal blood supply (clears acid) |
| Prostaglandins |
A common pitfall
Switching to NSAID suppositories does not solve the problem, because COX-1 inhibition and reduced prostaglandin synthesis is a systemic effect, not a local contact effect on the stomach.
Next steps
- Stop or minimise the NSAID; test for H. pylori; consider upper GI endoscopy, especially with alarm features.
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