A 57-year-old male presents to the GP with a 7-month history of epigastric pain which gets worse after eating. Over the same time period, he has lost his appetite and 1.5kg unintentionally. He has a past medical history of rheumatoid arthritis and a smoking history of 31 pack years. He admits that he often uses over-the-counter antacids, which help occasionally. He is referred for a two-week wait upper gastrointestinal endoscopy, which reveals granulation tissue with a necrotic layer.

Which of the following is the most likely diagnosis?

Options:
explanation: Zollinger-Ellison syndrome presents with recurrent ulcers in the stomach and duodenum secondary to excessive gastrin levels released from gastrinomas, which are malignant. Gastrin stimulates mucosal growth of the stomach and the release of acid from gastric parietal cells. These patients also present with diarrhoea due to excessive gastric acid leading to inactivation of lipase and subsequent fat malabsorption. Endoscopy would reveal multiple ulcers, as well as thickened gastric folds. This condition is commonly associated with multiple endocrine neoplasia 1 (MEN1.) Treatment is with high dose PPI or somatostatin analogues.
name: Zollinger-Ellison syndrome
label: c
answer: no
explanation: Oesophageal cancer typically presents with progressive dysphagia, initially for solids and eventually for liquids, as well as hoarseness of the voice if there is compression of the recurrent laryngeal nerve which runs close to the oesophagus in the thorax. Risk factors include smoking, acid reflux (due to Barrett's oesophagus), and high levels of alcohol intake. Helicobacter pylori causes achlorhydria chronically, and as such is actually protective against oesophageal adenocarcinoma. Weight loss and anorexia may also occur. This patient's endoscopy reveals no oesphageal lesion, with the only finding in the stomach, and reports no dysphagia. Therefore, oesophageal malignancy is unlikely.
name: Oesophageal cancer
label: e
answer: no
explanation: Crohn's disease is an inflammatory bowel disorder, which can present with abdominal pain and weight loss. Additional clinical features usually include diarrhoea, which is absent in this case. Inflammation can be present throughout the entire GI tract,  from mouth to anus, and additional clinical features, such as mouth ulcers, may be present. The history of abdominal pain worse on eating, relieved by antacids, and the appearances on endoscopy, are not consistent with a diagnosis of Crohn's disease.
name: Crohn's disease
label: d
answer: no
explanation: This patient's endoscopy findings are in keeping with a peptic ulcer. His symptoms of epigastric pain, worsened on eating, typically indicate a gastric ulcer (with pain from duodenal ulcers relieved by eating.) This patient has rheumatoid arthritis, and it is possible he may use NSAIDs frequently; this, alongside his smoking history, places him at higher risk of peptic ulcer disease.  Another key risk factor is Helicobacter pylori infection, which this patient will be tested for during endoscopy. It is important to note that this patient was referred for endoscopy appropriately under the 2-week-wait pathway as he fit the criteria for urgent investigation due to his age over 55, weight loss, and abdominal pain, in line with NICE guidance.
name: Peptic ulcer disease
label: a
answer: yes
explanation: Gastric cancer may also present with epigastric pain, weight loss,  and anorexia. Patients may also have iron deficiency anaemia. Risk factors for gastric cancer are similar to peptic ulcer disease, and include smoking as well as Helicobacter pylori infection. The endoscopic appearances here are in keeping with an ulcer, however, as opposed to gastric cancer, and the clinical feature of pain worsening on eating should also raise suspicion of an ulcer.
name: Gastric adenocarcinoma
label: b
answer: no

Correct answer: a


Learning point: Peptic ulcer disease can present with epigastric pain exacerbated by eating, often associated with NSAID use and smoking history.