What is the best course of treatment for a 16-year-old patient with epigastric pain and vomiting?

Management of a 16-Year-Old with Epigastric Pain and Vomiting

Immediately obtain an ECG and check vital signs to exclude life-threatening causes, then start high-dose PPI therapy while pursuing urgent diagnostic workup, as persistent vomiting with epigastric pain is a red flag that excludes functional dyspepsia and mandates investigation for serious organic pathology.

Immediate Life-Threatening Exclusions

Cardiac Assessment

• Obtain an ECG within 10 minutes of presentation to rule out myocardial infarction, which can present atypically with epigastric pain in adolescents, especially females, with mortality rates of 10-20% if missed 1, 2.
• Check serial troponins at 0 and 6 hours 2.
• Myocardial infarction can present as the primary manifestation with epigastric pain alone 1, 2.

Vital Signs Assessment

• Check immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation or sepsis with high specificity 1.
• Examine for peritoneal signs (abdominal rigidity, absent bowel sounds, guarding) which suggest perforated peptic ulcer with 30% mortality if treatment is delayed 3, 1, 2.

Urgent Laboratory Workup

Order the following tests immediately 1:

• Complete blood count (to assess for anemia, leukocytosis)
• C-reactive protein
• Serum lactate levels
• Liver and renal function tests
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis, with 80-90% sensitivity and specificity 1, 2

Imaging Strategy

If Diagnosis is Unclear or Peritoneal Signs Present

• CT abdomen and pelvis with IV contrast is the gold standard 1, 2.
• CT findings for perforated peptic ulcer include 3, 1:
  • Extraluminal gas (97% of perforations)
  • Fluid or fat stranding along gastroduodenal region (89%)
  • Ascites (89%)
  • Focal wall defect and/or ulcer (84%)
  • Wall thickening (72%)

If Patient is Stable Without Peritoneal Signs

• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis 2.
• Non-urgent endoscopy is appropriate for treatment-resistant symptoms 3.

Immediate Empiric Treatment

Start high-dose PPI therapy immediately while awaiting diagnostic workup 1:

• Omeprazole 20-40 mg once daily before meals
• Healing rates: 80-90% for duodenal ulcers, 70-80% for gastric ulcers 1, 2

Antiemetic Therapy

• If vomiting is severe and gastroparesis is suspected, metoclopramide can be considered 4.
• Critical caveat: In adolescents, acute dystonic reactions occur more frequently (approximately 1 in 500 patients), especially in those under 30 years of age, usually within the first 24-48 hours 5.
• If dystonic reactions occur, inject 50 mg diphenhydramine intramuscularly 5.

Differential Diagnosis Considerations

Common Gastrointestinal Causes

• Peptic ulcer disease: Incidence 0.1-0.3%, with complications in 2-10% of cases 1, 2.
• Gastroesophageal reflux disease: Affects 42% of Americans monthly 1.
• Gastric volvulus: Rare but significant cause of non-bilious vomiting in adolescents, diagnosed with upper GI barium study showing stomach rotation 6.

Less Common but Important Causes

• Duodenal injury: Epigastric pain (100%) with vomiting (100%) is the usual presentation in blunt upper abdominal trauma 7.
• Hyperthyroidism: Can present with persistent vomiting, epigastric pain, and weight loss; check for sinus tachycardia as a clue 8.
• Duodenal tuberculosis: Consider in endemic areas or with systemic symptoms (fever, weight loss) 9.

Helicobacter pylori Testing

• Offer non-invasive testing for H. pylori in patients without alarm features 3.
• If infected, provide eradication therapy 3.
• This is appropriate after excluding life-threatening causes and if endoscopy is not immediately indicated 3.

Surgical Consultation Criteria

Immediate surgical consultation if 3:

• Signs of perforation (sudden severe pain, peritoneal signs, fever, abdominal rigidity)
• Hemodynamic instability
• CT evidence of perforation or free air

Surgical intervention for perforated ulcer 3:

• Laparoscopic/open simple or double-layer suture with or without omental patch for small perforations
• Distal gastrectomy for large perforations near the pylorus or suspicion of malignancy

Antibiotic Therapy if Perforation Confirmed

For Immunocompetent, Non-Critically Ill Adolescents with Adequate Source Control 3:

• Amoxicillin/Clavulanate 2 g/0.2 g q8h
• Duration: 4 days if source control is adequate

If Beta-Lactam Allergy 3:

• Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h

Critical Pitfalls to Avoid

• Never dismiss cardiac causes regardless of age in patients with epigastric pain 1, 2.
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 2.
• Persistent vomiting is a red flag that excludes functional dyspepsia and mandates investigation for structural disease 1.
• Avoid assuming all epigastric pain is GERD-related without excluding other serious causes 10.
• Monitor for extrapyramidal symptoms if metoclopramide is used, especially in this age group 5.