What is the next management plan for a 34-year-old lady with indigestion and normal laboratory results, including Haemoglobin (Hb) within normal limits, Haematocrit (Hct) within normal limits, Mean Corpuscular Volume (MCV) within normal limits, Mean Corpuscular Haemoglobin (MCH) within normal limits, Red Blood Cell (RBC) count within normal limits, Platelet count within normal limits, White Blood Cell (WBC) count within normal limits, and no signs of anaemia or infection?

Management Plan for a 34-Year-Old Lady with Indigestion

The most appropriate next management plan for this 34-year-old lady with indigestion and normal laboratory results is to offer non-invasive testing for Helicobacter pylori (H. pylori) followed by appropriate eradication therapy if positive, or empirical acid suppression therapy if negative.

Initial Assessment and Diagnosis

Based on the clinical presentation and normal laboratory values, this patient likely has functional dyspepsia (FD), which is defined as:

• Bothersome epigastric pain or burning
• Early satiation and/or postprandial fullness
• Duration greater than 8 weeks
• Absence of structural disease explaining the symptoms 1

The patient's laboratory results show:

• Normal hemoglobin (118 g/L)
• Normal hematocrit, MCV, MCH, RBC count
• Platelets at the upper limit of normal (400 x 10^9/L)
• Normal white cell count and differential

These normal values rule out anemia, which is reassuring as iron deficiency anemia would warrant further investigation, particularly in adults 1, 2.

Management Algorithm

Step 1: H. pylori Testing

• Offer non-invasive H. pylori testing (urea breath test or stool antigen test) 1
• If positive: Provide appropriate eradication therapy
• If negative: Proceed to empirical acid suppression therapy

Step 2: Empirical Acid Suppression Therapy

• Prescribe a proton pump inhibitor (PPI) such as omeprazole 20mg once daily for 4-8 weeks 1, 3
• Monitor for response after 2-4 weeks
• If no response, consider changing drug class or dosing 4

Step 3: Follow-up Assessment

• If symptoms resolve with initial therapy, stop treatment after 4-8 weeks
• If symptoms recur, another course of the same treatment is justified 1, 4
• If symptoms persist despite therapy, consider referral for further evaluation

Additional Considerations

Lifestyle Modifications

• Regular aerobic exercise is strongly recommended 1
• Identify and address potential dietary triggers
• Establish good sleep hygiene and stress management techniques

When to Consider Endoscopy

Endoscopy is not indicated as the first step in this case because:

• The patient is under 55 years of age
• There are no alarm symptoms mentioned (such as weight loss, dysphagia, persistent vomiting)
• Laboratory values are normal
• No family history of gastro-esophageal cancer is mentioned 1

Potential Pitfalls to Avoid

1. Overinvestigation: Avoid unnecessary endoscopy in young patients without alarm features 1
2. Inadequate treatment duration: Ensure PPI therapy is continued for the full recommended course (4-8 weeks) 1, 4
3. Overlooking psychological factors: Functional dyspepsia can be exacerbated by stress and anxiety 1
4. Drug interactions with PPIs: Be aware that PPIs like omeprazole can interact with medications such as clopidogrel, diazepam, and warfarin 3
5. Long-term PPI risks: Extended PPI use may be associated with increased risk of bone fractures, vitamin B12 deficiency, and hypomagnesemia 3

Conclusion for Follow-up

If the patient fails to respond to both H. pylori eradication (if positive) and empirical acid suppression therapy, or if symptoms recur rapidly after stopping therapy, referral to gastroenterology would be appropriate for consideration of further investigation and management options 1.