A 52-year-old man with a 10-year history of rheumatoid arthritis has been on naproxen 500 mg BD for 3 years. He now presents with epigastric pain, nausea, and melena. Which investigation is most appropriate to confirm NSAID-induced gastropathy and guide further management?

Explanation

## Investigation of Choice for NSAID-Induced Gastropathy **Key Point:** Upper gastrointestinal endoscopy is the gold standard investigation for diagnosing NSAID-induced gastric ulcers, erosions, and associated complications (bleeding, perforation). ### Why Endoscopy is Superior 1. **Direct visualization** — allows direct inspection of the gastric mucosa and identification of ulcers, erosions, or hemorrhage 2. **Biopsy capability** — can obtain tissue samples to exclude malignancy or H. pylori infection 3. **Therapeutic potential** — permits hemostasis (injection, cautery, clip placement) if active bleeding is present 4. **Staging of injury** — accurately grades severity of mucosal damage ### Clinical Context This patient has: - **Risk factors for NSAID gastropathy:** age >50, prolonged NSAID use (3 years), no gastroprotection mentioned - **Alarm symptoms:** melena (upper GI bleeding), epigastric pain - **Acute presentation:** requires urgent endoscopic evaluation **High-Yield:** NSAID-induced ulcers classically occur in the antrum and lesser curve of the stomach; duodenal ulcers are more common with H. pylori or acid hypersecretion. ### Comparison with Other Investigations | Investigation | Role | Limitation in this case | |---|---|---| | **Upper GI endoscopy** | Gold standard; diagnostic + therapeutic | None — indicated | | **Fecal occult blood test** | Detects blood loss | Non-specific; cannot localize source or guide therapy | | **Serum gastrin** | Diagnoses Zollinger-Ellison syndrome | Not relevant; no history of refractory ulcers or diarrhea | | **CT abdomen** | Detects perforation, obstruction | Not first-line; misses mucosal lesions; less sensitive for active bleeding | **Clinical Pearl:** Patients on chronic NSAIDs with GI symptoms require endoscopy urgently if there is evidence of bleeding (melena, hematemesis, anemia). Empirical PPI therapy without endoscopy risks missing alternative diagnoses (malignancy, peptic ulcer disease from H. pylori).