What is the best approach to manage stomach ache in a 55-year-old woman with potential gastrointestinal disorders, such as gastroesophageal reflux disease (GERD) or peptic ulcer disease?

Management of Stomach Ache in a 55-Year-Old Woman

For a 55-year-old woman with new-onset stomach ache, perform a full blood count and test for Helicobacter pylori using a stool antigen or urea breath test; if positive, provide eradication therapy, and if negative or symptoms persist after eradication, initiate empirical proton pump inhibitor (PPI) therapy for 4-8 weeks. 1

Initial Assessment and Red Flags

At age 55, this patient crosses a critical threshold requiring heightened vigilance for serious pathology 1:

• Urgent endoscopy is warranted only if she has weight loss accompanying the stomach pain 1
• Non-urgent endoscopy should be considered if she has treatment-resistant symptoms, raised platelet count, or persistent nausea/vomiting 1
• Urgent abdominal CT scanning is indicated if she is ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1

Critical pitfall: Do not automatically order endoscopy in patients ≥55 years without alarm features (weight loss, dysphagia, bleeding, anemia, persistent vomiting) 1. The absence of alarm symptoms allows for initial non-invasive management.

First-Line Diagnostic and Treatment Approach

Step 1: Test for Helicobacter pylori

• Use stool antigen test or 13C-urea breath test (not serology, which has lower specificity) 1
• If positive: Provide eradication therapy (typically triple therapy with PPI plus two antibiotics for 10-14 days) 1
• Do not confirm eradication unless she has increased risk factors for gastric cancer (family history of gastroesophageal cancer, ethnicity from high-risk area) 1

The rationale: H. pylori accounts for approximately 5-10% of dyspepsia cases and most peptic ulcers not related to NSAIDs 1. Eradication prevents future complications including gastric adenocarcinoma 1.

Step 2: Empirical Acid Suppression

If H. pylori negative or symptoms persist after eradication:

• Prescribe a PPI (omeprazole 20-40 mg daily, or equivalent) for 4-8 weeks taken before meals 1, 2
• PPIs are superior to H2-receptor antagonists for symptom relief and healing in functional dyspepsia and GERD 1, 3, 4
• Emphasize PPI safety to the patient, as concerns about side effects often lead to non-adherence 1

Important caveat: In populations with H. pylori prevalence ≤10%, empirical PPI therapy may be more cost-effective than test-and-treat as the initial strategy 1. However, test-and-treat remains the recommended approach due to cancer prevention benefits 1.

Lifestyle and Non-Pharmacologic Interventions

Recommend regular aerobic exercise as this has strong evidence for improving functional dyspepsia symptoms 1

Additional measures to discuss:

• Weight management if overweight 1
• Avoiding eating within 2-3 hours of bedtime 1
• Elevating the head of the bed for nighttime symptoms 1

Evidence gap: There is insufficient evidence to recommend specific dietary therapies as first-line treatment 1, though individual trigger food avoidance may be reasonable.

When Symptoms Persist Despite Initial Management

If No Response After 4-8 Weeks of PPI:

Consider endoscopy at this point to exclude organic pathology (peptic ulcer, erosive esophagitis, malignancy) 1

If endoscopy is normal:

• Establish the diagnosis of functional dyspepsia 1
• Explain to the patient that functional dyspepsia is a disorder of gut-brain interaction, not a psychological condition, and that her symptoms are real 1
• Establishing an empathic doctor-patient relationship reduces healthcare utilization and improves quality of life 1

Escalation Options for Refractory Symptoms:

• Increase PPI to twice daily dosing 1
• Add nighttime H2-receptor antagonist (ranitidine 150 mg or famotidine 20 mg at bedtime) for nocturnal symptoms 1, 5
• Consider neuromodulators: Low-dose tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) have analgesic properties independent of mood effects and modulate pain processing in the brain and spinal cord 1, 6

Refer to gastroenterology if symptoms are severe, refractory to first-line treatments, or if diagnostic doubt exists 1

Critical Medication Considerations

Never prescribe opioids for chronic functional abdominal pain as they cause narcotic bowel syndrome, dependence, and paradoxically worsen pain through central sensitization 1, 6

NSAIDs should be used with extreme caution in patients ≥60 years due to increased risk of peptic ulcer disease and gastrointestinal bleeding 1. If the patient is taking NSAIDs, consider discontinuation or co-prescription of PPI for gastroprotection 1.

Long-Term Management Strategy

After symptom resolution:

• Taper PPI to the lowest effective dose that maintains symptom control 1
• Reassess appropriateness of continued PPI use within 12 months if long-term therapy is needed 1
• Most patients with functional dyspepsia will have a chronic, relapsing course requiring ongoing management 1

Common pitfall: Avoid repetitive testing once functional dyspepsia is established, as this increases costs without benefit and reinforces illness behavior 6. Limited investigations are appropriate, but exhaustive workup should be avoided 6.