What is the best next step for a 55-year-old woman with progressive abdominal pain, worsening upper abdominal pain after eating, nausea, and significant weight loss, currently taking omeprazole (prilosec) and antacids?

Endoscopy with Biopsy is the Best Next Step for This Patient

For a 55-year-old woman with progressive abdominal pain, significant weight loss, and worsening symptoms despite omeprazole therapy, endoscopy with biopsy is the best next step in management. 1

Rationale for Endoscopy with Biopsy

• This patient presents with multiple alarm features that warrant urgent investigation:

  • Age ≥55 years with dyspepsia and significant weight loss (9.1 kg in 6 months) 1
  • Worsening upper abdominal pain despite acid suppression therapy (omeprazole) 1
  • Pain that awakens her at night, suggesting a more serious underlying condition 1
  • Feeling of fullness and nausea, which could indicate gastric outlet obstruction or malignancy 1

• The British Society of Gastroenterology and American Gastroenterological Association guidelines specifically recommend urgent endoscopy for patients aged ≥55 years with dyspepsia and weight loss due to increased risk of gastro-oesophageal malignancy 1

• Endoscopy allows for direct visualization of the upper GI tract and collection of tissue samples for histological examination, which is crucial for diagnosing conditions such as peptic ulcer disease, malignancy, or other inflammatory conditions 1

Why Other Options Are Less Appropriate

• Upper gastrointestinal series (option 1):

  • Less sensitive than endoscopy for detecting mucosal abnormalities 1
  • Cannot provide tissue samples for histology or H. pylori testing 1
  • Guidelines specifically state that "endoscopy should be preferred over upper gastrointestinal radiography because it has greater diagnostic accuracy" 1

• H. pylori testing alone (option 3):

  • While H. pylori testing is important, it should not delay endoscopy in a patient with alarm features 1
  • The patient's symptoms have persisted despite omeprazole therapy, suggesting either treatment-resistant disease or an alternative diagnosis requiring direct visualization 1, 2

Management Algorithm

1. Immediate step: Endoscopy with biopsy (recommended option) 1

   • Allows direct visualization of the upper GI tract
   • Enables tissue sampling for histology and H. pylori testing
   • Can identify or rule out malignancy, peptic ulcer disease, or other pathologies

2. If endoscopy reveals H. pylori infection:

   • Initiate eradication therapy with a proton pump inhibitor plus two antibiotics 1, 3
   • Triple therapy with omeprazole, amoxicillin, and metronidazole has shown higher eradication rates than dual therapy 3

3. If endoscopy reveals peptic ulcer disease:

   • Continue PPI therapy (omeprazole 20-40mg daily) 4, 5
   • Address underlying causes (H. pylori, NSAIDs) 4

4. If endoscopy reveals malignancy:

   • Refer for appropriate oncological management
   • Stage the disease appropriately

5. If endoscopy reveals functional dyspepsia:

   • Continue acid suppression therapy 1
   • Consider alternative diagnoses if symptoms persist despite therapy 2

Important Clinical Considerations

• The patient's significant weight loss (9.1 kg) over 6 months is particularly concerning and meets criteria for urgent investigation 1

• Treatment-resistant dyspepsia in patients over 55 years is an indication for endoscopy according to multiple guidelines 1

• Nocturnal symptoms that awaken the patient suggest a more serious organic pathology rather than functional dyspepsia 1

• The patient is already on omeprazole without symptom resolution, indicating the need for diagnostic evaluation rather than empirical therapy escalation 1, 2

• Biopsy during endoscopy is essential not only for ruling out malignancy but also for detecting less common conditions such as eosinophilic gastroenteritis that may not respond to standard PPI therapy 2