Clinical Assessment

Patient Summary

• 22-year-old female
• Epigastric/stomach pain worse on standing → relieved by lying or sitting
• Running nose for 1 day
• Currently on methylprednisolone (corticosteroid)

Most Likely Diagnosis: Steroid-Induced Gastritis / Peptic Ulcer Disease (PUD)

Why Methylprednisolone Causes Gastric Injury

The risk is especially high when corticosteroids are combined with NSAIDs. The risk with steroids alone is moderate but real, particularly with high doses or prolonged use.

Why Pain is Worse Standing, Relieved Lying/Sitting

• In the upright position, gravity pools acid in the dependent antrum/pyloric region → direct mucosal contact → pain
• Lying down (supine) distributes acid more evenly, reducing focal pressure on the ulcer
• Sitting forward can also shift weight off the inflamed area

Differential Diagnoses to Consider

Note: The running nose (1 day) is likely the primary condition for which methylprednisolone was prescribed (allergic rhinitis). It does not directly cause the stomach pain.

Prescribed Medicines & Rationale

1. Proton Pump Inhibitor (PPI) — ⭐ First-line gastroprotection

2. H2 Receptor Antagonist — Alternative/adjunct

3. Sucralfate — Mucosal protectant (adjunct)

• Forms a protective barrier over ulcer base
• Dose: 1 g QID (4×/day) on empty stomach
• Does not reduce acid but physically coats and protects mucosa

4. Antacids (for symptomatic relief)

• Aluminium hydroxide + Magnesium hydroxide (e.g., Gelusil, Digene)
• Provide rapid symptom relief; not curative
• Take 1–2 hours after meals and at bedtime

5. Continue Methylprednisolone (for the Rhinitis)

• Should be taken with food to minimize gastric irritation
• Use the lowest effective dose for the shortest duration
• Consider switching to enteric-coated formulation if available

Summary Management Plan

1. PPI (e.g., Omeprazole 20 mg OD before breakfast) ← mandatory
2. Sucralfate 1 g TDS/QID (optional but helpful)
3. Take methylprednisolone WITH food
4. Test for H. pylori (urea breath test or stool antigen) → eradicate if positive
5. Avoid: NSAIDs, alcohol, spicy food, caffeine
6. Upper GI endoscopy if symptoms persist or "alarm features" present

Alarm Features Requiring Urgent Endoscopy

• Age >50 with new-onset symptoms (not applicable here)
• Unexplained weight loss
• Persistent vomiting
• Dysphagia
• Iron-deficiency anemia / GI bleeding
• Abdominal mass

🚨 Urgent Pain Relief + Investigations

Immediate Priority — Pain Relief (Right Now)

STEP 1 — Immediate Symptom Relief (within minutes)

Practical tip: Give antacid first for instant relief while the PPI takes effect (PPIs need 1–2 hours to reach full effect).

STEP 2 — Rescue Analgesic (if pain still severe)

⚠️ Avoid NSAIDs (ibuprofen, diclofenac) — they will worsen gastric mucosal injury.

STEP 3 — Anti-nausea (if vomiting present)

Investigations to Order NOW

Urgent Bloods

Imaging

Special Tests

Complete Prescription Summary

Rx:
1. Tab. Pantoprazole 40 mg — 1 tab OD before breakfast × 4 weeks
2. Tab. Dicyclomine 20 mg — 1 tab TDS (3×/day) before meals
3. Syrup Antacid (Mg(OH)₂ + Al(OH)₃) — 2 tbsp after meals and at bedtime
4. Tab. Paracetamol 500 mg — 1-2 tabs TDS PRN for pain
5. Tab. Methylprednisolone — continue WITH FOOD (do not take empty stomach)
6. Ondansetron 4 mg TDS if nausea present

Investigations: CBC, Lipase, LFT, USG Abdomen, H. pylori stool antigen

Advice:
- Take steroid tablet WITH food or milk
- Avoid spicy food, caffeine, alcohol, NSAIDs
- Return immediately if: vomiting blood, black stools, severe worsening pain

Red Flags — Send to ER Immediately if ANY of these:

• 🔴 Vomiting blood (hematemesis)
• 🔴 Black tarry stools (melena) → suggests GI bleeding
• 🔴 Rigid/board-like abdomen → perforation
• 🔴 Sudden severe pain radiating to back → pancreatitis
• 🔴 Fever + jaundice → cholangitis