From the Guidelines
For a patient presenting with epigastric burning pain, I recommend starting with a thorough history and physical examination to identify potential causes, followed by a trial of lifestyle modifications and consideration of a proton pump inhibitor (PPI) or H. pylori testing as indicated, with referral for endoscopy if symptoms persist or alarm features are present, as suggested by the most recent guidelines from the British Society of Gastroenterology 1.
When evaluating a patient with epigastric burning pain, it is essential to consider the potential causes, including acid-related disorders, functional dyspepsia, and H. pylori infection. The initial management should focus on lifestyle modifications, such as avoiding spicy foods, alcohol, NSAIDs, and large meals.
- Key components of the initial evaluation include:
- Thorough history and physical examination
- Lifestyle modifications
- Consideration of PPI therapy for suspected acid-related disorders
- H. pylori testing if infection is suspected
- If symptoms persist despite initial management, or if alarm features are present, such as weight loss, vomiting, anemia, or age >55 years, referral for endoscopy is recommended, as suggested by the American Gastroenterological Association 1 and the AGA clinical practice update on the personalized approach to the evaluation and management of GERD 1.
- The workup should target the most common causes of burning stomach pain, including acid hypersecretion, mucosal inflammation, and bacterial infection, while ensuring serious conditions are not missed.
- A stepwise diagnostic approach, as outlined in the AGA clinical practice update 1, will help identify the underlying mechanisms driving symptoms and guide a precision management approach.
From the Research
Appropriate Workup for Epigastric Burning Pain
The appropriate workup for a patient presenting with epigastric burning pain involves several steps, including:
- Evaluating the patient's symptoms and medical history to determine the potential cause of the pain 2
- Considering the patient's age and presence of alarm features, such as bleeding or weight loss, to determine the need for prompt esophagogastroduodenoscopy (EGD) 2
- Testing for Helicobacter pylori infection and considering a trial of acid suppression with a proton pump inhibitor (PPI) 3, 2
- Evaluating the patient's response to initial therapy and adjusting the treatment plan as needed 2
Potential Causes of Epigastric Burning Pain
The potential causes of epigastric burning pain include:
- Peptic ulcer disease, which can be caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use 3
- Gastroesophageal reflux disease (GERD), which can cause symptoms such as heartburn and regurgitation 4
- Functional dyspepsia, which is a chronic or recurrent pain or discomfort centered in the upper abdomen 2
Diagnostic Tests
Diagnostic tests that may be used to evaluate epigastric burning pain include:
- Upper endoscopy, which can be used to visualize the upper gastrointestinal tract and diagnose conditions such as peptic ulcer disease or GERD 3, 4
- Esophageal manometry and ambulatory reflux monitoring, which can be used to evaluate the function of the esophagus and diagnose conditions such as GERD 4
- Testing for Helicobacter pylori infection, which can be used to diagnose peptic ulcer disease 3, 2
Treatment Options
Treatment options for epigastric burning pain depend on the underlying cause and may include:
- Acid suppression with a PPI, which can be used to treat conditions such as peptic ulcer disease or GERD 3, 4, 2
- Eradication of Helicobacter pylori infection, which can be used to treat peptic ulcer disease 3
- Discontinuation of NSAID use, which can be used to treat peptic ulcer disease caused by NSAID use 3