What should be done for a patient with nausea (N), vomiting (V), stomach ache, and ongoing epigastric pain that has worsened over the past few days?

Management of Nausea, Vomiting, and Epigastric Pain

This patient requires immediate symptomatic treatment with ondansetron 8 mg sublingual or oral every 4-6 hours, along with urgent evaluation for alarm features that would necessitate expedited diagnostic workup before the scheduled follow-up. 1

Immediate Assessment for Red Flags

The 2-month history of epigastric pain with recent worsening demands evaluation for serious pathology. You must immediately assess for the following alarm features:

• Severe, sudden-onset epigastric pain that could indicate perforated peptic ulcer 2
• Neurologic symptoms (headache, focal deficits, altered mental status) requiring immediate workup 1
• Signs of peritonitis (abdominal rigidity, rebound tenderness, absent bowel sounds) 2
• Severe dehydration or metabolic abnormalities 1, 3

If any of these are present, the patient cannot wait weeks for follow-up and needs emergency evaluation.

Initial Laboratory Testing

Order the following labs immediately to exclude metabolic causes and assess severity: 1, 3

• Complete blood count
• Serum electrolytes (looking for hypokalemia, hypochloremia from vomiting) 3
• Glucose
• Liver function tests
• Lipase (to exclude pancreatitis)
• Urinalysis

Also consider: 3

• Hypercalcemia screening
• Thyroid function tests
• Pregnancy test if applicable

Medication Review

Review all current medications as potential culprits, specifically: 1

• Opioids
• Antibiotics
• NSAIDs (particularly relevant given epigastric pain)
• Chemotherapy agents
• Antidepressants

Critical caveat: In this age group, obtain a cannabis use history, as Cannabis Hyperemesis Syndrome is increasingly common and presents with cyclic nausea/vomiting and epigastric pain. 3

Symptomatic Treatment

Start ondansetron 8 mg sublingual or oral every 4-6 hours as first-line antiemetic. 1

Alternative options if ondansetron is ineffective or contraindicated: 1

• Prochlorperazine 5-10 mg every 6-8 hours
• Promethazine 12.5-25 mg every 4-6 hours

Monitor for QTc prolongation with ondansetron, especially if combined with other QT-prolonging medications. 3

Empiric Acid Suppression Therapy

Given the 2-month history of epigastric pain, initiate a proton pump inhibitor empirically while awaiting further evaluation: 4

• Omeprazole 20 mg once daily before meals for presumed peptic ulcer disease or gastritis 4
• Alternative: Ranitidine 150 mg twice daily (though PPI preferred) 5

This addresses the most likely cause (peptic ulcer disease, gastritis, or GERD) and provides symptom relief while diagnostic workup proceeds.

Imaging and Endoscopy Decisions

Do NOT pursue imaging or endoscopy if this is truly a single, self-limited episode without alarm features. 1 However, this patient has chronic symptoms (2 months) with recent worsening, which changes the calculus.

Expedite upper endoscopy (EGD) or upper GI imaging before the scheduled follow-up if: 3

• Symptoms persist beyond 4 weeks despite PPI therapy
• Any alarm features are present
• Age >60 years (increased malignancy risk)
• Unintentional weight loss

Avoid gastric emptying studies in this acute setting. 1

Supportive Care Measures

Ensure adequate hydration and electrolyte repletion: 3

• Target fluid intake ≥1.5 L/day
• Small, frequent meals
• Thiamin supplementation to prevent Wernicke's encephalopathy if vomiting is severe or prolonged 3

Critical Pitfalls to Avoid

Never use antiemetics if mechanical bowel obstruction is suspected (this can mask progressive ileus). 3 Examine for distension, high-pitched bowel sounds, or complete obstruction signs.

Do not dismiss the 2-month epigastric pain history. While treating symptoms, this patient needs definitive diagnosis—either expedite the follow-up or arrange urgent EGD if symptoms worsen or persist beyond 4 weeks of PPI therapy. 1, 3

Monitor for extrapyramidal symptoms if using dopamine antagonists (prochlorperazine, metoclopramide), particularly in younger patients. 3

Follow-Up Timing

This patient should NOT wait weeks for follow-up if:

• Symptoms worsen despite treatment
• New alarm features develop
• Vomiting becomes severe or persistent (≥4 episodes suggesting cyclic vomiting syndrome) 1

Counsel the patient to return immediately for: 2

• Increasing abdominal pain
• Light-headedness
• Worsening nausea or vomiting
• Any new concerning symptoms