What treatment is recommended for a 15-year-old with ongoing abdominal pain and a burning sensation, suspected to have Gastroesophageal Reflux Disease (GERD) or functional dyspepsia?

Treatment for a 15-Year-Old with Abdominal Pain and Burning Sensation Suspected of GERD or Functional Dyspepsia

For a 15-year-old with ongoing abdominal pain and burning sensation suspected to have GERD or functional dyspepsia, empirical acid suppression therapy with a proton pump inhibitor (PPI) such as omeprazole is the recommended first-line treatment. 1, 2

Diagnostic Considerations

• The symptoms of abdominal pain and burning sensation could indicate either GERD or functional dyspepsia (FD), which commonly overlap in approximately one-third of patients 2, 3
• Distinguishing features:
  • GERD: Burning sensation that starts in the epigastrium but radiates to the chest (heartburn) 2
  • FD: Pain primarily in the upper abdomen/epigastrium, may be present during fasting or exacerbated by meals, unrelated to defecation 2
• In adolescents without alarm symptoms (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea, or significant vomiting), extensive diagnostic testing is usually unnecessary 4

Treatment Algorithm

Step 1: Lifestyle Modifications

• Advise regular aerobic exercise 2
• Identify and avoid food triggers that may worsen symptoms, including:
  • Coffee 5
  • Chocolate 6
  • Fatty and fried foods 6
  • Acidic/sour foods and beverages 6
• Recommend smaller, more frequent meals 6
• For GERD symptoms specifically, suggest sleeping with 30-45 degree elevated head or upper chest 6

Step 2: First-Line Pharmacological Treatment

• Prescribe empirical acid suppression therapy with a PPI such as omeprazole 1, 2
  • Dosing: Age-appropriate dose for 4-8 weeks
  • Omeprazole is FDA-approved for treatment of GERD symptoms in patients 2 years and older 1
  • For erosive esophagitis, treatment may be extended to 8 weeks 1

Step 3: Evaluation of Response

• If symptoms improve with PPI therapy, this supports a diagnosis of GERD or acid-sensitive FD 2
• If symptoms persist despite 4-8 weeks of PPI therapy, consider:
  • Testing for Helicobacter pylori with breath or stool test 2
  • If H. pylori positive, provide eradication therapy 2
  • If H. pylori negative or symptoms persist after eradication, consider referral to gastroenterology 2

Special Considerations

• Avoid unnecessary endoscopy in adolescents without alarm symptoms 2
• Consider non-urgent endoscopy only if symptoms are treatment-resistant 2
• Screen for psychological factors that may exacerbate symptoms, as anxiety and depression are common in patients with chronic abdominal pain 4

Important Caveats

• Monitor for potential side effects of PPIs, including:
  • Diarrhea (potentially Clostridium difficile-associated) 1
  • Risk of bone fractures with long-term use 1
  • Decreased absorption of certain nutrients 1
• Limit PPI therapy to the shortest duration needed, as long-term safety data in pediatric patients beyond 12 months is limited 1
• If symptoms persist despite appropriate therapy, referral to a pediatric gastroenterologist is appropriate for further evaluation 2

Follow-up Recommendations

• Schedule follow-up within 4-8 weeks to assess response to treatment 1
• If symptoms resolve, consider tapering PPI to the lowest effective dose or discontinuing after 8-12 weeks 1
• For recurrent symptoms after discontinuation, consider maintenance therapy or further diagnostic evaluation 2