What is the recommended treatment for a 10-year-old with epigastric pain?

Management of Epigastric Pain in a 10-Year-Old Child

In a 10-year-old child presenting with epigastric pain, consider eosinophilic esophagitis (EoE) as a key diagnostic possibility and proceed with upper endoscopy with biopsies if symptoms are significant enough to warrant investigation, as abdominal pain is a common presenting symptom in this age group and macroscopic appearance alone is unreliable for diagnosis. 1

Age-Specific Diagnostic Considerations

Eosinophilic Esophagitis in Children

• Children aged 9-10 years commonly present with abdominal pain as the primary manifestation of EoE, with a median age of 9.0 years for this presentation pattern 1
• Epigastric pain occurs in approximately 8% of children with EoE undergoing endoscopy 1
• Younger children show non-specific symptoms while older children (>6 years) are more likely to present with abdominal pain or dysphagia 1
• Approximately 21% of children with biopsy-proven EoE have a macroscopically normal-appearing esophagus on endoscopy, making biopsies essential 1

Functional Dyspepsia Considerations

• While functional dyspepsia can present with epigastric pain, the Rome IV criteria require symptom onset at least 6 months prior to diagnosis with symptoms active in the past 3 months 1
• The Rome Foundation has developed less restrictive "clinical criteria" requiring only 8 weeks of symptoms for practical clinical use 1
• Functional dyspepsia is primarily a diagnosis of exclusion after structural disease has been ruled out 1, 2

Diagnostic Approach

When to Pursue Endoscopy

• All children undergoing endoscopy for upper gastrointestinal symptoms should have biopsies taken to diagnose EoE (strong recommendation, moderate evidence) 1
• The non-specific nature of presenting symptoms in children, especially younger ones, combined with the unreliability of macroscopic appearance, necessitates biopsy sampling 1
• If symptoms are refractory to proton pump inhibitor (PPI) therapy and suggest GERD-like presentation, endoscopy with biopsies is strongly recommended to exclude EoE 1

Key Clinical Features to Assess

• Food avoidance behaviors (difficult textures like bread and meat) or excessive water drinking with meals may indicate EoE with insidious onset 1
• Associated atopic conditions increase the likelihood of EoE 1
• Presence of vomiting, feeding difficulties, or failure to thrive should be evaluated 1
• Alarm symptoms including weight loss, dysphagia, recurrent vomiting, GI bleeding, or family history of upper GI cancer warrant urgent investigation 3

Initial Management Strategy

Empirical PPI Trial

• For symptomatic GERD or epigastric pain in children aged 2-16 years, omeprazole dosing is weight-based: 10 mg once daily for children 10 to <20 kg, or 20 mg once daily for children ≥20 kg 4
• Treatment duration is up to 4 weeks for symptomatic GERD 4
• Take omeprazole before meals; antacids may be used concomitantly 4

When PPI Trial Fails

• Children with persistent typical GERD symptoms despite PPI therapy should undergo esophagogastroduodenoscopy (OGD) with sufficient esophageal biopsies, as 70% of children with EoE had previously failed PPI treatment 1
• The substantial overlap between GERD and EoE symptoms makes endoscopic evaluation essential when empirical therapy fails 1

Common Pitfalls to Avoid

Diagnostic Errors

• Do not rely on endoscopic appearance alone in children—macroscopic findings correlate only moderately with histological scores (r=0.61) and peak eosinophil counts (r=0.55) 1
• Do not assume all epigastric pain is acid-related—consider serious conditions and age-appropriate differentials 3
• Do not delay endoscopy in children with alarm symptoms or those failing empirical therapy 1, 3

Management Considerations

• Persistent vomiting suggests another disorder beyond simple functional dyspepsia and warrants further investigation 1
• In children under 6 years, feeding difficulties and failure to thrive are more common presentations than isolated epigastric pain 1
• H. pylori testing should be considered if peptic ulcer disease is suspected 3

Algorithmic Approach

1. Initial assessment: Evaluate for alarm symptoms (weight loss, dysphagia, vomiting, bleeding, family history) 3

   • If present → proceed directly to endoscopy with biopsies 1

2. If no alarm symptoms: Assess for atopic history and food avoidance behaviors 1

   • Consider empirical PPI trial (omeprazole 10-20 mg daily based on weight) for 4 weeks 4

3. If symptoms persist after 4 weeks of PPI therapy:

   • Proceed to upper endoscopy with multiple esophageal biopsies to evaluate for EoE and other structural pathology 1

4. If endoscopy and biopsies are normal: Consider functional dyspepsia diagnosis after 8 weeks of symptoms 1, 2