What could be causing my generalized stomach pain that improves with food intake and has lasted for 4 weeks without other gastrointestinal symptoms?

Generalized Stomach Pain Relieved by Food for 4 Weeks

Your symptom pattern—generalized stomach pain that improves with eating and has persisted for 4 weeks without diarrhea, constipation, nausea, or vomiting—most strongly suggests peptic ulcer disease (specifically duodenal ulcer) or epigastric pain syndrome (a form of functional dyspepsia), and you should be tested for H. pylori infection and started on acid suppression therapy. 1, 2

Why This Diagnosis is Most Likely

Your specific symptom pattern is highly characteristic of acid-related pathology:

• Duodenal ulcers classically cause pain that is relieved by food intake because eating buffers gastric acid and reduces direct acid contact with the ulcer. 2 Pain typically occurs several hours after eating or during fasting, and hunger provokes the discomfort in most cases. 2

• Epigastric pain syndrome (EPS), defined by the Rome IV criteria, presents with epigastric pain and/or burning that may improve with meal ingestion and can occur during fasting. 3, 1, 2 This pattern strongly suggests acid-related pathology. 1

• The absence of nausea, vomiting, and altered bowel habits makes other common diagnoses less likely—specifically, this argues against irritable bowel syndrome (where pain relates to defecation) 3, gastroparesis (which causes nausea/vomiting) 3, and functional diarrhea or constipation. 3

Immediate Diagnostic Steps

Test for H. pylori First

You must be tested for H. pylori infection using either a stool antigen test or urea breath test. 1 This is the critical first step because:

• If H. pylori is positive, eradication therapy eliminates peptic ulcer mortality risk and prevents ulcer recurrence. 1
• Testing should occur before starting any acid suppression therapy, as PPIs can cause false-negative results. 3

When to Pursue Endoscopy

You do not need urgent endoscopy unless alarm features are present. 3, 1 The British Society of Gastroenterology recommends 2-week wait endoscopy only if you have: 3

• Dyspepsia with weight loss if age ≥25 years
• Age >40 years from an area at increased risk of gastric cancer or with family history of gastro-oesophageal malignancy

Consider non-urgent endoscopy if: 3

• Treatment-resistant dyspepsia if age ≥25 years

Baseline Blood Work

Obtain a full blood count to screen for anemia, which could indicate bleeding from an ulcer. 3

Treatment Algorithm

If H. pylori Positive

Provide H. pylori eradication therapy immediately. 1 This eliminates the underlying cause of peptic ulcer disease and prevents recurrence. 1

If H. pylori Negative or Symptoms Persist After Eradication

Initiate full-dose PPI therapy as first-line treatment. 1 The evidence demonstrates that patients with epigastric pain as the predominant symptom respond well to PPI therapy. 1

Specific PPI dosing instructions: 1

• Take PPI 30-60 minutes before a meal (preferably breakfast) for optimal acid suppression
• Initial treatment duration: 4-8 weeks
• For duodenal ulcer specifically, most patients heal within 4 weeks. 4

Alternative option if PPIs are unavailable: H2-receptor antagonists like ranitidine (though currently withdrawn in many markets) were effective for duodenal ulcers, with 69% healing at 4 weeks versus 31% with placebo. 4

Why Not Other Diagnoses?

Functional Dyspepsia vs. Peptic Ulcer Disease

While your symptoms could represent functional dyspepsia, the Rome IV criteria require symptoms to be present for more than 8 weeks for a formal diagnosis. 3 At 4 weeks, you're in a diagnostic gray zone where peptic ulcer disease remains a significant concern and must be ruled out first.

Irritable Bowel Syndrome (IBS)

IBS is unlikely because: 3

• Abdominal pain in IBS is related to defecation—it's relieved or exacerbated by bowel movements. 3
• You report no diarrhea or constipation, which are cardinal features of IBS. 3
• IBS pain is typically lower abdominal, whereas food-relieved pain suggests upper GI pathology. 2

Gastroparesis

Gastroparesis causes nausea, vomiting, early satiety, and postprandial fullness—symptoms you explicitly deny having. 3 Pain that improves with eating is inconsistent with gastroparesis, where eating typically worsens symptoms.

Critical Pitfalls to Avoid

Do not assume this is "just stress" or functional dyspepsia without testing for H. pylori first. 1 H. pylori-positive peptic ulcer disease is a treatable organic condition that, if left untreated, carries mortality risk from bleeding or perforation. 1

Do not start PPI therapy before H. pylori testing. 3 PPIs suppress H. pylori and can cause false-negative test results, leading to missed diagnosis and treatment. 3

Do not use opioids for this pain. 3, 5 Opioids are complicated by dependence, serious infection risk, mortality, narcotic bowel syndrome, and gut dysmotility. 3

Do not ignore alarm features if they develop. 3, 1 New onset of weight loss, bleeding, anemia, persistent vomiting, or dysphagia requires urgent evaluation regardless of symptom duration. 3

Expected Timeline

• If H. pylori positive: Symptoms should improve within 1-2 weeks of starting eradication therapy, with complete ulcer healing expected by 4 weeks. 4

• If H. pylori negative and started on PPI: Symptom relief typically occurs within 1-2 weeks, with most patients experiencing significant improvement by 4-8 weeks. 1, 4

• If symptoms persist beyond 8 weeks despite appropriate therapy: Reassess for functional dyspepsia, consider endoscopy if not yet performed, and evaluate for other causes including gastric ulcer (which causes pain immediately after eating, not relief). 3, 2