What is the diagnosis and management for a 36-year-old with abdominal pain, significant weight loss, night sweats, and epigastric tenderness, prescribed pantoprazole (proton pump inhibitor) and Buscopan (antispasmodic)?

Urgent Diagnostic Workup Required for Suspected Gastric Malignancy

This 36-year-old patient requires immediate upper endoscopy with biopsy to rule out gastric cancer, given the constellation of alarm features: significant unintentional weight loss (substantial kg loss over 2.5 months), night sweats, epigastric pain, and nausea. 1

Critical Red Flags Present

This patient presents with multiple alarm features that mandate urgent investigation:

• Unintentional weight loss of substantial magnitude over 2.5 months is the strongest predictor requiring endoscopic evaluation 2
• Night sweats combined with weight loss raises concern for malignancy or systemic disease 3
• Age 36 with progressive symptoms despite empiric PPI therapy (pantoprazole prescribed but not taken)
• Epigastric pain radiating to left side with associated nausea suggests potential gastric pathology 1

Immediate Diagnostic Algorithm

Step 1: Upper Endoscopy with Biopsy (Within 2 Weeks)

Endoscopy is the reference standard for diagnosing gastric cancer and must be performed urgently. 1 The FDA label for pantoprazole explicitly warns that "symptomatic response to therapy with pantoprazole sodium does not preclude the presence of gastric malignancy" and recommends "additional follow-up and diagnostic testing in adult patients who have a suboptimal response." 4

Key endoscopic findings to assess:

• Nodular or irregular gastric wall thickening 1
• Ulceration with mass effect or coarse, lobulated folds 1
• Mucosal abnormalities in the gastric body or antrum 1

Step 2: CT Abdomen and Pelvis with IV Contrast

If endoscopy cannot be performed immediately or if imaging is needed for staging, obtain CT abdomen/pelvis with IV contrast and neutral oral contrast (water or dilute barium). 1 This imaging protocol is specifically designed to detect:

• Nodular or irregular gastric wall thickening 1
• Soft tissue attenuation of wall thickening (rather than edema) 1
• Lymphadenopathy and distant metastases 1
• Perforation with ulcerated mass 1

Do NOT order CT without IV contrast, as it will be significantly less sensitive for detecting gastric malignancy. 1

Step 3: Complete Laboratory Workup

While awaiting endoscopy, complete the following:

• Complete blood count to assess for anemia (iron deficiency anemia can indicate chronic GI blood loss from malignancy) 3
• Inflammatory markers (ESR, CRP) - elevated levels increase likelihood of significant pathology 2
• Albumin level - hypoalbuminemia suggests chronic disease or malabsorption 2
• Stool occult blood testing (already ordered, ensure follow-up)

What This Is NOT

This presentation is inconsistent with simple gastritis or peptic ulcer disease alone given the severity of weight loss and systemic symptoms. While the patient was empirically prescribed pantoprazole and Buscopan (antispasmodic), these medications should NOT delay definitive diagnosis. 4

This is NOT irritable bowel syndrome (IBS). The AGA guidelines for IBS management are irrelevant here because:

• IBS does not cause unintentional weight loss 1
• Night sweats are not a feature of IBS 1
• Alarm features mandate organic disease exclusion before considering functional diagnoses 1

Differential Diagnosis to Consider

Based on the clinical presentation, the differential includes:

1. Gastric adenocarcinoma (most concerning given alarm features) 1
2. Gastric lymphoma (can present with weight loss, night sweats, and epigastric pain) 3
3. Small bowel pathology (Crohn's disease, small bowel tumor, stricture) - weight loss with abdominal pain increases diagnostic yield of capsule endoscopy if upper endoscopy is negative 2
4. Pancreatic pathology (though pain radiation to left suggests gastric origin) 1

Critical Management Pitfalls to Avoid

1. Do NOT continue empiric PPI therapy without tissue diagnosis. The FDA explicitly warns that symptomatic response does not exclude malignancy, and older patients require endoscopy. 4 At 36, this patient is young but has alarm features that supersede age considerations.

2. Do NOT attribute symptoms to "gastritis" or "functional dyspepsia" without endoscopic confirmation. The significant weight loss (substantial kg over 2.5 months) and night sweats demand exclusion of malignancy. 1, 2

3. Do NOT delay endoscopy for further non-invasive testing. Endoscopy with biopsy is the definitive diagnostic test and should be performed within 2 weeks given alarm features. 1

4. Do NOT dismiss the subcutaneous lump noted in the left parasternal region - document size, mobility, and consider biopsy if lymphadenopathy is suspected, as this could represent metastatic disease. 1

Immediate Management While Awaiting Endoscopy

• Discontinue Buscopan - antispasmodics are inappropriate until organic pathology is excluded 1
• Continue pantoprazole 40 mg daily to provide symptomatic relief and reduce acid-related symptoms, but emphasize this does not exclude serious pathology 4
• Nutritional support - given significant weight loss, consider nutritional assessment and supplementation
• Close follow-up - ensure patient understands the urgency and has clear instructions to return immediately if symptoms worsen (hematemesis, melena, severe pain, vomiting)

Expected Timeline

• Endoscopy: within 2 weeks (sooner if symptoms progress)
• CT imaging: within 1 week if endoscopy is delayed or for staging if malignancy suspected
• Laboratory results: within 48-72 hours to guide urgency of workup

The combination of significant unintentional weight loss, night sweats, and epigastric pain in a 36-year-old mandates aggressive investigation for gastric malignancy or other serious organic pathology. 1, 2 Functional diagnoses or empiric therapy without tissue diagnosis are inappropriate and potentially dangerous in this clinical context.