What is the best approach to manage a 14-year-old male patient with symptoms of giddiness, particularly in the early morning and sometimes during the day, who has a history of a one-day episode of vomiting treated with pantoprazole, and is experiencing stress due to family concerns?

Management of a 14-Year-Old Male with Giddiness, Vomiting, and Family Stress

This patient requires immediate discontinuation of pantoprazole and a comprehensive evaluation for the underlying cause of giddiness, as the single-day vomiting episode does not warrant proton pump inhibitor therapy and the primary concern is the recurrent morning giddiness which may indicate a serious neurological, cardiovascular, or metabolic condition. 1, 2

Critical Initial Assessment

Red Flag Evaluation

• Assess for bilious vomiting immediately, as this represents a surgical emergency requiring urgent fluoroscopy upper GI series 1
• The single episode of vomiting does not meet criteria for cyclic vomiting syndrome (which requires at least 3 discrete episodes per year, each lasting <7 days, separated by at least 1 week of baseline health) 3, 1
• Morning giddiness (dizziness/vertigo) in an adolescent warrants investigation for:
  • Orthostatic hypotension (measure blood pressure supine and standing)
  • Cardiac arrhythmias (obtain ECG)
  • Hypoglycemia (check fasting glucose)
  • Vestibular disorders
  • Anxiety/panic disorder (given family stress) 2

Laboratory Evaluation Required

Obtain complete blood count, serum electrolytes, glucose, liver function tests, and urinalysis to exclude metabolic causes and assess for dehydration 2

• Consider testing for hypercalcemia, hypothyroidism, and adrenal insufficiency if clinically indicated 2
• Urine drug screen is warranted given the age group, particularly to assess for cannabis use which can cause Cannabis Hyperemesis Syndrome 2

Why Pantoprazole Should Be Discontinued

Inappropriate Indication

• A single day of vomiting does not constitute gastroesophageal reflux disease (GERD) or peptic ulcer disease 3
• Pantoprazole is indicated for GERD only after failure of 4-8 weeks of empirical once-daily PPI therapy, escalated to twice-daily if needed 3
• The American College of Physicians recommends empirical PPI therapy only for typical GERD symptoms (heartburn, regurgitation), not isolated vomiting 3

Potential Harm in This Context

• PPIs can mask symptoms of serious underlying conditions requiring urgent evaluation 2
• In adolescents with unexplained symptoms, establishing the correct diagnosis takes priority over empirical acid suppression 1, 2

Appropriate Management of the Vomiting Episode

If Vomiting Recurs or Persists

Initiate dopamine receptor antagonists titrated to maximum benefit and tolerance, such as metoclopramide or prochlorperazine 2

• Metoclopramide 10 mg orally every 6 hours is particularly effective for gastric stasis 2
• Monitor for extrapyramidal symptoms with dopamine antagonists, particularly in young males 2

Consider adding ondansetron (5-HT3 antagonist) if symptoms persist after initial treatment 2

• Ondansetron 4-8 mg orally every 8 hours as needed 3
• Monitor for QTc prolongation when using ondansetron 2

Supportive Care

Ensure adequate fluid intake of at least 1.5 L/day and dietary modifications including small, frequent meals 2

• Address any electrolyte imbalances identified on laboratory testing, particularly hypokalemia and hypomagnesemia 2

Addressing the Psychological Component

Stress and Anxiety Management

Given the family stress component, consider that anxiety can manifest with physical symptoms including dizziness and nausea 3

• For anticipatory nausea/vomiting related to anxiety, consider alprazolam 0.25 mg orally 2-3 times daily (lower dose appropriate for adolescents) 3
• Behavioral therapy, guided imagery, and hypnosis with systematic desensitization may be helpful 3
• Referral to mental health services for family stress management is appropriate

Critical Pitfalls to Avoid

• Never use antiemetics if mechanical bowel obstruction is suspected, as this can mask progressive ileus 2
• Do not continue pantoprazole without a clear indication (typical GERD symptoms unresponsive to initial therapy) 3
• Avoid repeated endoscopy or imaging unless new symptoms develop 2
• Do not dismiss the morning giddiness as secondary to the vomiting—this requires independent evaluation as it may represent the primary pathology 1

Follow-Up Plan

• If symptoms completely resolve, no further intervention needed beyond addressing family stress
• If giddiness persists beyond 1-2 weeks, refer to pediatric neurology or cardiology for specialized evaluation
• If vomiting becomes recurrent (≥3 episodes per year with stereotypical pattern), reassess for cyclic vomiting syndrome 3, 1
• One-time upper GI imaging or esophagogastroduodenoscopy only if vomiting becomes chronic or alarm symptoms develop (dysphagia, bleeding, weight loss) 2