What is the next step in managing a young healthy male with nausea and vomiting triggered by eating for 3 weeks, with normal C-Reactive Protein (CRP), normal barium swallow, and normal Helicobacter pylori (H. pylori) breath test?

Upper Endoscopy (Esophagogastroduodenoscopy) is the Next Step

In a young healthy male with 3 weeks of food-triggered nausea and vomiting, with normal CRP, barium swallow, and H. pylori testing, upper endoscopy (EGD) should be performed to establish a definitive diagnosis of functional dyspepsia and exclude structural pathology. 1

Rationale for Endoscopy

The British Society of Gastroenterology guidelines explicitly state that patients with persistent upper gastrointestinal symptoms require endoscopy to provide a positive diagnosis of functional dyspepsia and exclude serious causes. 1 While this patient has had a barium swallow, endoscopy offers superior visualization of the gastric and duodenal mucosa and allows for tissue sampling. 1

• Duration of symptoms (3 weeks) warrants investigation beyond initial non-invasive testing, as chronic symptoms lasting beyond 2-4 weeks require more definitive evaluation. 1
• Barium studies have limitations - while they can identify structural abnormalities and gastroparesis, they miss mucosal lesions, inflammation, and other pathology that endoscopy readily detects. 2
• Gastric biopsies during endoscopy can document H. pylori status histologically (more definitive than breath testing alone) and identify other mucosal abnormalities. 1

What Endoscopy Will Accomplish

Upper endoscopy serves multiple critical functions in this clinical scenario:

• Excludes structural disease including peptic ulcer disease, gastric or duodenal erosions, malignancy, and celiac disease (via duodenal biopsies). 1
• Provides definitive diagnosis of functional dyspepsia when structural pathology is absent, allowing confident initiation of appropriate therapy. 1
• Identifies subtle mucosal changes that barium studies cannot detect, such as gastritis, duodenitis, or early erosive disease. 1

Post-Endoscopy Management Algorithm

If Endoscopy is Normal (Functional Dyspepsia Confirmed):

First-line empirical therapy should target the predominant symptom pattern:

• For nausea/vomiting triggered by eating (dysmotility-like pattern): Start a prokinetic agent such as metoclopramide 10 mg three times daily before meals. 1, 3, 4
• For epigastric pain/discomfort (ulcer-like pattern): Initiate proton pump inhibitor therapy. 1

Second-line options if first-line fails:

• Switch medication class (e.g., from prokinetic to PPI or vice versa) as patients may have been initially misclassified. 1
• Consider adding a neuromodulator (tricyclic antidepressant at low doses) for visceral hypersensitivity. 1
• Trial of high-dose PPI therapy if GERD component suspected. 1

If Endoscopy Identifies Pathology:

Treat the specific condition identified (ulcer disease, erosive gastritis, etc.) according to standard protocols. 1

Important Clinical Pitfalls to Avoid

Do not diagnose functional dyspepsia without endoscopy in patients with persistent symptoms beyond 2-4 weeks, as this risks missing treatable organic disease. 1 The normal barium swallow does not exclude mucosal pathology.

Do not order gastric emptying studies before endoscopy - gastroparesis evaluation should follow structural exclusion via endoscopy, not precede it. 1, 5 The diagnostic sequence matters: endoscopy first establishes whether symptoms arise from structural disease versus functional disorder.

Avoid extensive metabolic workup in a young healthy patient with isolated GI symptoms and normal inflammatory markers - the yield is extremely low and delays definitive diagnosis. 6, 5

Do not empirically treat with prokinetics long-term without establishing diagnosis - metoclopramide carries a black box warning for tardive dyskinesia with prolonged use, making diagnostic certainty essential before committing to extended therapy. 3, 4

Why Other Tests Are Not the Next Step

• Gastric emptying scintigraphy: Should be reserved for post-endoscopy evaluation if gastroparesis is specifically suspected based on symptom pattern and normal structural evaluation. 1, 2
• CT abdomen: Low yield in young patients with isolated upper GI symptoms and normal physical exam; barium study already excluded gross structural abnormalities. 5
• Empirical PPI trial: While reasonable in some primary care settings, 3 weeks of symptoms warrants definitive evaluation rather than further empirical therapy. 1