What are the recommended labs, imaging, and treatment for a patient with stomach pain upon waking?

Recommended Labs, Imaging, and Treatment for Stomach Pain Upon Waking

For patients with stomach pain upon waking, a targeted diagnostic approach with CT abdomen and pelvis with IV contrast is recommended as the initial imaging study, followed by appropriate laboratory tests including complete blood count, liver enzymes, and H. pylori testing.

Initial Diagnostic Approach

Laboratory Testing

• Basic workup:
  • Complete blood count (CBC) to assess for infection or inflammation 1
  • Comprehensive metabolic panel to evaluate liver and kidney function
  • Stool Hemoccult test (recommended for screening purposes) 1
  • H. pylori testing (stool antigen or urea breath test) - essential for all patients with epigastric pain 1
  • Erythrocyte sedimentation rate (ESR) - particularly in younger patients 1
  • Serum albumin level 1
  • Stool for ova and parasites (if diarrhea is present) 1

Imaging Studies

• First-line imaging:

  • CT abdomen and pelvis with IV contrast - provides the highest sensitivity and specificity for detecting abdominal pathology 1
  • For epigastric pain specifically, upper GI series with fluoroscopy may be appropriate, especially if hiatal hernia or gastric cancer is suspected 1

• Second-line imaging (based on initial findings):

  • Plain abdominal radiography has limited utility but may be considered if bowel obstruction is suspected 1
  • Ultrasound if biliary disease is suspected 1

Diagnostic Algorithm Based on Symptom Pattern

For predominant epigastric pain:

1. Rule out serious conditions with CT abdomen/pelvis with IV contrast
2. Test for H. pylori
3. Consider upper GI series if structural abnormalities are suspected 1
4. If negative, consider trial of antispasmodic medication 1

For pain with constipation:

1. Trial of increased dietary fiber (25g/day) 1
2. If persistent, consider whole gut transit test or anorectal motility studies 1

For pain with diarrhea:

1. Stool studies for ova/parasites and occult blood 1
2. Consider lactose/dextrose H2 breath test if loose/watery stools 1
3. Consider celiac disease testing 1
4. If negative, trial of loperamide 1

Treatment Approach

First-line treatments:

• For H. pylori positive patients:

  • Antibiotic treatment regimen to eradicate infection 1

• For functional dyspepsia (after negative workup):

  • Antispasmodic medications for pain predominant symptoms 1
  • Proton pump inhibitors for acid-related symptoms 1
  • Tricyclic antidepressants for frequent or severe pain 1

Lifestyle modifications:

• Regular exercise 1
• Identification and avoidance of food triggers 1
• Stress management techniques 1

Special Considerations

Red flags requiring urgent evaluation:

• Age >50 years with new-onset symptoms 1
• Family history of upper GI cancers 1
• Weight loss, anemia, or GI bleeding 1
• Severe, persistent pain unresponsive to initial management 1

Common pitfalls to avoid:

1. Overlooking H. pylori infection - All patients with epigastric pain should be tested 1
2. Excessive dietary restrictions - May lead to malnutrition without evidence of benefit 1
3. Missing serious pathology - Appropriate imaging is essential, especially in older patients 1
4. Overreliance on plain radiographs - Limited utility in diagnosing causes of abdominal pain 1
5. Failure to reassess - If symptoms persist despite treatment, reevaluation is necessary 1

For patients with persistent symptoms despite initial management, referral to a multidisciplinary team including gastroenterologists, dietitians, and psychologists may be beneficial to ensure comprehensive care and avoid unnecessary procedures 1.