What are the treatment options for epigastric pain, nausea, and vomiting after 24 hours without sleep?

Epigastric Pain, Nausea, and Vomiting After 24 Hours Without Sleep

Start high-dose proton pump inhibitor therapy immediately (omeprazole 20-40 mg once daily before meals) while simultaneously ruling out life-threatening causes with an ECG and basic laboratory workup. 1, 2

Immediate Life-Threatening Exclusions

Obtain an ECG within 10 minutes to rule out myocardial infarction, which can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed. 1, 2

Check vital signs immediately for:

• Tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation or sepsis with high specificity 1
• Peritoneal signs including abdominal rigidity, absent bowel sounds, and guarding, which suggest perforated peptic ulcer with 30% mortality if treatment is delayed 1, 2

Urgent Laboratory Workup

Order the following tests immediately:

• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis, with 80-90% sensitivity and specificity 1, 3
• Complete blood count and C-reactive protein 1, 3
• Serum lactate levels 1, 3
• Liver and renal function tests 1, 3
• Serum electrolytes and glucose 1, 3

Immediate Symptomatic Treatment

While awaiting diagnostic workup, provide symptomatic relief with antiemetics:

• Ondansetron 8 mg sublingual every 4-6 hours for nausea and vomiting (obtain baseline ECG first due to QTc prolongation risk) 1, 4
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours as an alternative, which also provides sedation 1
• Prochlorperazine 5-10 mg every 6-8 hours as another option 1
• Metoclopramide can be considered as a dopamine receptor antagonist, particularly if gastroparesis is suspected 1, 5, 6, 7

Critical Clinical Context: Sleep Deprivation Connection

The 24-hour sleep deprivation history raises concern for cyclic vomiting syndrome (CVS), a condition where sleep deprivation is a known trigger. 8

If CVS is suspected based on episodic pattern:

• Sumatriptan via nasal spray (delivered in head-forward position) or subcutaneous injection combined with an antiemetic is the most effective abortive treatment 8
• Inducing sedation is often an effective abortive strategy in CVS, and promethazine may be particularly useful in this regard 8
• Benzodiazepines (such as alprazolam in sublingual or rectal form) may be needed as part of an "abortive cocktail" 8

Imaging Strategy

If diagnosis remains unclear or peritoneal signs are present, order CT abdomen and pelvis with IV contrast as the gold standard for diagnosing perforated peptic ulcer and other emergencies. 1, 2

CT findings for perforation include:

• Extraluminal gas (97% sensitivity) 1, 2
• Fluid or fat stranding along gastroduodenal region (89%) 1, 2
• Ascites (89%) 1, 2
• Focal wall defect/ulcer (84%) 1, 2

Definitive Diagnostic Workup

Upper endoscopy is definitive when the patient is stable for diagnosing peptic ulcer disease, gastritis, and esophagitis. 1, 3

Do not delay endoscopy if alarm features are present:

• Persistent vomiting (which you have) 1, 3
• Weight loss 1, 3
• Anemia 1, 3
• Dysphagia 1, 3
• Age-dependent risk factors for gastric cancer 1, 3

Critical Pitfalls to Avoid

Persistent vomiting is a red flag that excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer disease or acute coronary syndrome, according to Rome IV criteria. 1, 3

Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age—this is a potentially fatal error. 1, 2

Do not attribute symptoms to sleep deprivation alone without ruling out organic pathology, as persistent vomiting suggests another disorder beyond functional disease with high risk of missing serious pathology. 1, 3

Surgical Consultation Criteria

Immediate surgical consultation is required for signs of perforation, hemodynamic instability, or CT evidence of perforation or free air. 1

Expected Clinical Course

If CVS is confirmed and episode is aborted:

• Recovery phase typically lasts 1-2 days, during which priority is consuming electrolyte-rich fluids (sports drinks) or nutrient drinks 8
• Patients may feel nauseated or have dyspeptic symptoms but generally can tolerate moderate volumes of liquid intake 8

If peptic ulcer disease is diagnosed:

• High-dose PPI therapy achieves healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2