Discussion
The answer is B: Peptic ulcer disease - Pyloric stenosis.

The patient refused to undergo gastrointenstinal endoscopy, but accepted to undergo a barium meal examination, which showed severe pyloric stenosis (Figure 2). The computer tomography of the abdomen showed severe stomach dilatation without masses or other abnormal findings (Figure 3). He underwent vagotomy and enteroanastomosis. The biopsy of the removed segment of the stomach did not show any malignant changes.

Peptic ulcer disease refers to duodenum or gastric ulceration and the main causes are Helicobacter pylori and NSAIDS¹. Predominant epigastric pain or discomfort that is periodic (present for some months and absent for others), relieved with food is important for the diagnosis. Nevertheless, even these classic features of peptic ulcer, though common in peptic ulcer are often present in functional dyspepsia².

Severe peptic ulcer resulting in hypertrophic pyloric stenosis (HPS) is a rare clinical problem nowadays. Symptoms include vomiting, nausea, early satiety, weight loss, epigastric pain especially after eating. The physical examination may not be helpful because the pyloric mass is difficult to palpate. On contrast radiography, the elongated narrow pylorus is again apparent: gastric emptying is delayed and the stomach may be dilated. Ultrasonography is the screening procedure of choice, whereas upper endoscopy is indicated to differentiate idiopathic HPS from carcinoma or chronic peptic ulcer disease³. Medical management of peptic ulcer has limited its complications and decreased the need for surgical treatment. Surgery (either by resective or non-resective gastric procedures) may be the treatment of choice in selected patients with complications of peptic ulcer ^4,5.

Functional or non-ulcer dyspepsia is a diagnosis of exclusion. Many patients with non-ulcer dyspepsia have multiple somatic complaints, as well as symptoms of anxiety and they use psychotropic agents. The Rome II criteria⁶ can be helpful: patients with functional dyspepsia should have persistent or recurrent symptoms without evidence of organic disease and without evidence that dyspepsia is relieved exclusively by defecation or associated with the onset of a change in stool frequency or stool form. However, unaided clinical diagnosis in primary care is unreliable⁷.

Gastroesophageal reflux disease (GERD) with or without esophagitis is caused by the reflux of stomach contents into the esophagus⁸. This can lead to esophageal inflammation. Risk factors for GERD include smoking, alcohol, calcium antagonists, nitrates and theophylline. Predominant heart burn, heart burn relieved by an antacid and heartburn exacerbated by stooping or lying flat is thought to be helpful in diagnosis⁹.

Upper gastrointestinal cancer is rare in patients younger than 55 years and men are more than twice as likely to have upper gastrointestinal cancer at any given age⁹. Alarming features such as progressive dysphagia, anemia, and weight loss may indicate underlying malignancy. Palpable epigastric mass or enlarged supraclavicular (Virchow) node raises the concern of gastric malignancy.

Other possible diagnosis may include biliary tract disease, pancreatitis or systemic disorders (parasitosis, diabetes) etc. However, the history in our case makes these diagnoses rather unlikely. For example, biliary colic typically occurs in attacks with long periods of freedom from pain, which when it comes is located in the right upper quadrant and radiates to the tip of the shoulder.

In conclusion, since clinical diagnosis in vomiting and dyspepsia remains unreliable, alarming features such as dysphagia, weight loss, anemia or predisposing and risk factors for organic diseases indicate patients at higher risk for serious disease who should undergo further evaluation without delay¹⁰.

Acknowledgements
This case was prepared for our website by Dr. Dimitrios A. Moutzouris, MD and Stylianos Manetas, MD, PhD.

References
1. Ford AC, Delaney BC, Forman D, Moayyedi P. Eradication therapy in Helicobacter pylori positive peptic ulcer disease: systematic review and economic analysis. Am J Gastroenterol. 2004;99:1833-1855.
2. Spiller RC. ABC of the upper gastrointestinal tract: Anorexia, nausea, vomiting and pain. BMJ 2001;323:1354-1357.
3. Redel C and Zwiener RJ- Anatomy and anomalies of the stomach and duodenum. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th eds. Philadelphia W.B.Saunders 1998 p.567-568.
4. Chang TM, Chen TH, Shih CM, Gueng MK, Tsou SS. Partial or complete circular duodenectomy with highly selective vagotomy for severe obstructing duodenal ulcer disease: an initial experience. Arch Surg 1998 Sep;133(9):998-1001.
5. Wang CS, Tzen KY, Chen PC, Chen MF. Effects of highly selective vagotomy and additional procedures in gastric emptying in patients with obstructing duodenal ulcer. World J Surg 1994;18:131-138
6. Dickerson L., Pharm D and King D. Evaluation and Management of Nonulcer Dyspepsia. AFP 2004;70(1):107-114.
7. The Danish Dyspepsia Study Group. Value of the Unaided clinical diagnosis in dyspeptic patients in primary care. AJG 2001;96(5):1417-1421.
8. Kahrilas PJ, Pandolfino JE. The target of therapies: pathophysiology of gastroesophageal reflux disease. Gastrointest Endosc Clin N Am. 2003;13:1-17.
9. Moayyedi P, Talley N., Fennerty B, Vakil N. Can the clinical history distinguish between organic and functional dyspepsia? JAMA 2006;295(13):1566-1576.
10. Kapoor N., Bassi A., Sturgess R. and Bodger K. Predictive value of alarm features in a rapid access upper gastrointestinal cancer service. Gut 2005;54:40-45.