What is the best course of action for a patient with severe epigastric pain radiating from the back, with no chest pain, fever, or cough, currently taking Ranitidine (H2 receptor antagonist), Ketorolac (nonsteroidal anti-inflammatory drug), Paracetamol (acetaminophen), and Omeprazole (proton pump inhibitor)?

Immediate Diagnostic Workup Required

This patient requires urgent evaluation for acute pancreatitis or perforated peptic ulcer, not just symptomatic treatment with acid suppression and NSAIDs. The combination of severe (10/10) epigastric pain radiating to the back is a classic presentation for these life-threatening conditions that demand immediate diagnostic imaging and potential surgical consultation 1.

Critical Red Flags in This Presentation

• Severe epigastric pain radiating to the back (10/10 severity) is the hallmark presentation of acute pancreatitis or posterior penetrating peptic ulcer 1
• The current medication regimen is inappropriate and potentially dangerous - giving ketorolac (an NSAID) to a patient with suspected upper GI pathology significantly increases the risk of ulcer perforation and bleeding 2, 3

Immediate Actions Required

Stop ketorolac immediately - NSAIDs are contraindicated in patients with suspected peptic ulcer disease or acute abdominal pathology, as they significantly increase the risk of ulcer complications including perforation and bleeding 2, 3

Obtain urgent imaging:

• Abdominal ultrasound as first-line to evaluate for gallstones, pancreatic inflammation 1
• CT scan with IV contrast if ultrasound is non-diagnostic or if perforation is suspected (look for extraluminal gas, intra-abdominal fluid, thick reactive intestinal wall) 1

Check serum lipase/amylase immediately - elevated levels (>3x upper limit of normal) confirm acute pancreatitis, which requires completely different management than simple gastritis 1

Assess for peritoneal signs - abdominal rigidity, rebound tenderness, absent bowel sounds, or masked liver dullness suggest perforation requiring emergency surgical consultation 1

Appropriate Medical Management

If Imaging Rules Out Surgical Emergencies

Optimize acid suppression therapy:

• Increase omeprazole to 40 mg once daily (the current regimen with both ranitidine and omeprazole is redundant) - omeprazole is superior to ranitidine for both healing and symptom relief 1, 3
• Continue for 8 weeks to ensure complete healing 2

Pain management without NSAIDs:

• Use paracetamol (acetaminophen) alone for pain relief - it does not cause gastric injury 1, 2
• Avoid all NSAIDs going forward, as patients with NSAID-induced gastritis are at very high risk for recurrent complications 2

Test for H. pylori infection:

• H. pylori increases NSAID-related complications by 2-4 fold 2
• If positive, treat with triple therapy: PPI + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days 2

Common Pitfalls to Avoid

Do not treat severe epigastric pain radiating to the back as simple dyspepsia - this presentation demands investigation for pancreatitis, perforated ulcer, or acute mesenteric ischemia 1

Do not combine H2 antagonists (ranitidine) with PPIs (omeprazole) - this is redundant therapy, and PPIs are significantly more effective 1, 3

Never use NSAIDs in patients with suspected peptic ulcer disease - even with PPI therapy, NSAIDs significantly increase ulcer recurrence and complications 2, 3

When to Pursue Endoscopy

Urgent endoscopy is indicated if:

• Alarm symptoms develop: hematemesis, melena, significant weight loss, difficulty swallowing, or recurrent vomiting 2
• Symptoms persist despite 8 weeks of appropriate PPI therapy 2
• Patient is taking regular NSAIDs and presents with dyspeptic symptoms (can diagnose potentially life-threatening ulcer complications) 2

The patient requires immediate reassessment with appropriate imaging before continuing symptomatic treatment alone - the severity and radiation pattern of pain suggests pathology beyond simple gastritis that could be life-threatening if missed 1.