What is my diagnosis and treatment for persistent stomach pain despite taking omeprazole (proton pump inhibitor) and having a history of ulcers, with normal endoscopy and Prenovu scan results?

Diagnosis and Management of Persistent Stomach Pain Despite Omeprazole

You most likely have functional dyspepsia (ulcer-like subtype) with inadequate acid suppression, and you need to optimize your PPI therapy to full-dose continuous treatment rather than intermittent courses.

Your Clinical Picture

Your presentation is consistent with functional dyspepsia given:

• Endoscopy showing only ulcers (which have presumably healed but symptoms persist) 1
• Normal Prenovu scan ruling out structural abnormalities 1
• Symptom recurrence immediately after stopping omeprazole, indicating acid-related pain 1
• Severe pain affecting sleep quality, which significantly impacts your quality of life 1

The fact that omeprazole works while you're taking it but pain returns immediately when you stop is the key diagnostic clue—this confirms your symptoms are acid-mediated 1.

Immediate Treatment Plan

Step 1: Optimize PPI Dosing

• Take omeprazole 20 mg once daily continuously (not intermittently) before breakfast 1
• If 20 mg doesn't provide complete relief within 2 weeks, increase to omeprazole 40 mg once daily 1
• Continue treatment for at least 4-8 weeks to assess full response 2

Step 2: Test for H. pylori

• Get tested immediately using a urea breath test or stool antigen test (not blood test) 1
• If positive, you need triple therapy: omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily for 14 days 2
• H. pylori eradication eliminates future ulcer mortality risk, even if it doesn't completely resolve functional dyspepsia symptoms 1

Why Your Current Approach Isn't Working

You're stopping omeprazole too soon 1. The guidelines clearly state that patients with ulcer-like dyspepsia (epigastric pain as predominant symptom) require:

• Full-dose PPI therapy continuously, not intermittent courses 1
• On-demand therapy after initial symptom control, meaning you restart when symptoms return rather than stopping completely 1
• Many patients need long-term maintenance therapy to prevent symptom recurrence 1

Long-Term Management Strategy

After achieving symptom control (4-8 weeks):

1. Attempt therapy withdrawal to see if symptoms stay controlled 1
2. If symptoms recur (which is likely in your case):
   • Resume omeprazole at the effective dose 1
   • Consider on-demand therapy: take omeprazole only when symptoms occur, which reduces costs while maintaining quality of life 1
   • Some patients require continuous maintenance therapy indefinitely 1

If symptoms persist despite optimized PPI therapy:

• Consider high-dose PPI trial: omeprazole 40 mg twice daily for 2-4 weeks to confirm acid-related nature 1
• Rule out atypical GERD with 24-hour pH monitoring if high-dose PPI trial fails 1
• Consider adding a prokinetic agent if you have bloating, fullness, or early satiety alongside pain 1

Critical Points About Your Scoliosis

Your slight scoliosis is unlikely related to your stomach pain unless you're taking NSAIDs (ibuprofen, naproxen) for back pain 1. If you are:

• NSAIDs can cause ulcers and prevent healing even with PPI therapy 1
• Switch to acetaminophen for pain management 1
• If NSAIDs are absolutely necessary, continue omeprazole 20-40 mg daily as gastroprotection 1

What You Should NOT Do

• Don't stop omeprazole abruptly when symptoms improve—this guarantees recurrence 1
• Don't use antacids or H2-blockers (like famotidine) instead of omeprazole—they're less effective for your type of pain 1
• Don't assume you need repeat endoscopy unless you develop new alarm symptoms (weight loss, difficulty swallowing, vomiting blood) 2

Expected Outcomes

With proper continuous PPI therapy:

• 85-96% of refractory ulcers heal within 4-8 weeks 3, 4
• Pain relief occurs in 79-91% of patients within 2-4 weeks 1, 5
• Quality of life improves significantly over 3 months after symptom control 1
• You should be able to sleep without pain once adequate acid suppression is achieved 1

The bottom line: You need continuous, not intermittent, PPI therapy at an adequate dose, combined with H. pylori testing and eradication if positive. This approach will control your symptoms and allow you to sleep, dramatically improving your quality of life 1.