What is the next step in managing epigastric pain that worsens with eating, with negative complete blood count (CBC), comprehensive metabolic panel (CMP), amylase, and X-ray results in an urgent care setting?

From the Guidelines

In the urgent care setting for epigastric pain that worsens with eating and has negative initial workup (CBC, CMP, amylase, and x-ray), I recommend starting with a proton pump inhibitor (PPI) such as omeprazole 40mg once daily or pantoprazole 40mg once daily for 2-4 weeks. Additionally, provide symptomatic relief with antacids like Maalox or Mylanta 15-30ml as needed for breakthrough pain. Refer the patient to a gastroenterologist for follow-up within 1-2 weeks, as this presentation suggests possible peptic ulcer disease, gastritis, or gastroesophageal reflux disease (GERD) 1. Consider H. pylori testing with a stool antigen test or urea breath test if available. The patient should avoid NSAIDs, alcohol, spicy foods, caffeine, and acidic foods until diagnosis is confirmed. If symptoms worsen, include severe pain, vomiting, or dark/bloody stools, instruct the patient to go to the emergency department immediately. The rationale for PPI therapy is to reduce gastric acid production, allowing potential mucosal injuries to heal, while the referral ensures proper endoscopic evaluation to definitively diagnose the underlying condition.

Some key points to consider in the management of epigastric pain include:

• The use of fluoroscopy biphasic esophagram or fluoroscopy single-contrast esophagram or fluoroscopy upper GI series for initial imaging in certain clinical scenarios 1
• The importance of considering the clinical suspicion for gastric cancer, and the use of CT abdomen and pelvis with IV contrast or fluoroscopy upper GI series as equivalent alternatives for initial imaging in these cases 1
• The role of H. pylori testing and treatment in the management of dyspepsia, and the use of a test and treat strategy in low-risk patients 1
• The use of full dose PPI therapy as the first choice of therapy in patients with ulcer-like dyspepsia, and the consideration of prokinetic agents in patients with dysmotility-like dyspepsia 1

Overall, the management of epigastric pain requires a thoughtful and individualized approach, taking into account the patient's clinical presentation, medical history, and risk factors. By following a structured approach to diagnosis and treatment, clinicians can provide effective care for patients with epigastric pain and improve outcomes. It is also important to consider the potential complications of epigastric pain, such as perforation or bleeding, and to instruct patients to seek immediate medical attention if they experience severe symptoms. With prompt and appropriate treatment, many patients with epigastric pain can experience significant improvement in their symptoms and quality of life.

From the FDA Drug Label

Table 1: Recommended Dosage Regimen of Omeprazole in Adults by Indication Indication Dosage of Omeprazole Treatment Duration Treatment of Active Duodenal Ulcer 20 mg once daily 4 weeks

2.3 Administration Instructions • Take omeprazole delayed-release capsules before meals.

The next step in managing epigastric pain that worsens with eating, with negative complete blood count (CBC), comprehensive metabolic panel (CMP), amylase, and X-ray results in an urgent care setting could be to consider empiric treatment for gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD) with a medication such as omeprazole. The recommended adult dosage for treatment of symptomatic GERD or active duodenal ulcer is 20 mg once daily for up to 4 weeks or 4 weeks, respectively. However, this should be done under the guidance of a healthcare professional, as the diagnosis is not explicitly stated in the provided information 2.

• Key considerations:
  • Take omeprazole delayed-release capsules before meals.
  • Antacids may be used concomitantly with omeprazole delayed-release capsules.
  • If a dose is missed, administer as soon as possible, but do not take two doses at one time to make up for a missed dose.

From the Research

Next Steps in Managing Epigastric Pain

Given the negative results from the complete blood count (CBC), comprehensive metabolic panel (CMP), amylase, and X-ray, the next steps in managing epigastric pain that worsens with eating in an urgent care setting may involve:

• Further diagnostic testing to rule out other potential causes of epigastric pain, such as peptic ulcer disease (PUD) or gastroesophageal reflux disease (GERD) 3, 4, 5
• The use of clinical bedside ultrasonography (US) as a first-line imaging technique to evaluate acute epigastric pain, as it is rapid, noninvasive, and relatively inexpensive 6
• Consideration of a focused US protocol, such as the "$ approach", to systematically evaluate acute non-traumatic epigastric pain in an emergency setting 6
• Evaluation for other potential causes of epigastric pain, such as pancreatic or biliary disease, and consideration of imaging techniques like computed tomography (CT) or endoscopy if necessary 7
• Assessment of the patient's symptoms and medical history to determine the best course of treatment, which may include the use of proton pump inhibitors, antibacterial drugs, or other medications to manage PUD or other conditions 3, 4, 5