What is the best course of treatment for an adult patient with no significant medical history presenting with epigastric pain and nausea?

Management of Epigastric Pain with Nausea in Adults

Immediately obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which can present with isolated epigastric pain and carries 10-20% mortality if missed, then initiate high-dose PPI therapy (omeprazole 20-40 mg once daily) while completing diagnostic workup. 1, 2, 3

Immediate Life-Threatening Exclusions

Cardiac Assessment (First Priority)

• Never dismiss cardiac causes regardless of age or presentation - myocardial infarction presents atypically with epigastric pain as the primary manifestation in women, diabetics, elderly patients, and those with chronic renal disease 4, 1
• Obtain ECG within 10 minutes of presentation per European Society of Cardiology guidelines 4, 1
• Measure cardiac troponins at 0 and 6 hours - do not rely on single measurement 1, 2
• Associated symptoms suggesting cardiac origin include diaphoresis, dyspnea, and radiation to left arm, neck, or jaw 4

Surgical Emergency Assessment

• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis with high specificity 1, 5
• Examine for peritoneal signs: sudden severe pain becoming generalized, abdominal rigidity, absent bowel sounds, and guarding suggest perforated peptic ulcer with 30% mortality if treatment delayed 1, 5
• Order CT abdomen/pelvis with IV contrast if perforation suspected - shows extraluminal gas in 97%, fluid/fat stranding in 89%, ascites in 89%, and focal wall defect in 84% of perforated ulcers 4, 1, 5

Pancreatitis Evaluation

• Measure serum amylase (≥4x normal) or lipase (≥2x normal) with 80-90% sensitivity and specificity for acute pancreatitis 1, 5
• Characteristic presentation includes epigastric pain radiating to the back 1
• Overall mortality <10% but reaches 30-40% in necrotizing pancreatitis 1

Initial Diagnostic Workup

Laboratory Testing

• Complete blood count, comprehensive metabolic panel (liver and renal function), C-reactive protein, and serum lactate 1, 2, 5
• Serum electrolytes and glucose 1
• Serial cardiac troponins at 0 and 6 hours 1, 2
• Serum amylase or lipase 1, 2, 5

Imaging Strategy

• CT abdomen/pelvis with IV contrast is the gold standard when diagnosis unclear, identifying pancreatitis, perforation, and vascular emergencies 4, 1, 5
• Use neutral oral contrast (water or dilute barium) when gastric disease suspected to delineate intraluminal space 4
• IV contrast essential for assessing nodular wall thickening and soft tissue attenuation 4

Immediate Empiric Treatment

Proton Pump Inhibitor Therapy

• Start omeprazole 20-40 mg once daily before meals immediately while awaiting diagnostic workup 1, 2, 3
• Healing rates: 80-90% for duodenal ulcers, 70-80% for gastric ulcers 1, 5
• Most duodenal ulcers heal within 4 weeks; some require additional 4 weeks 3
• For gastric ulcers, treat for 4-8 weeks 3
• Take before meals; antacids may be used concomitantly 3

Antiemetic Therapy for Nausea

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 1
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Prochlorperazine 5-10 mg every 6-8 hours 1

Supportive Measures

• Maintain NPO status until surgical emergency excluded 1
• Provide IV access and fluid resuscitation if hemodynamically unstable 1
• Avoid NSAIDs - worsen peptic ulcer disease and increase bleeding risk 1

Management Based on Clinical Presentation

Patients Without Alarm Features

• Test for Helicobacter pylori infection using non-invasive testing 2
• If positive, provide eradication therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days 3
• If ulcer present at therapy initiation, continue omeprazole 20 mg once daily for additional 18 days 3
• Continue full-dose PPI therapy for 4-8 weeks if H. pylori negative or symptoms persist after eradication 2

Alarm Features Requiring Urgent Endoscopy

• Age ≥55 years in average-risk populations or ≥40 years in high-risk populations 2
• Persistent vomiting (excludes functional dyspepsia and mandates investigation) 2, 5
• Unintentional weight loss 2
• Dysphagia 2
• Family history of gastric or esophageal cancer 2
• Regular NSAID use 2

Refractory Symptoms After 4-8 Weeks

• Increase PPI to twice daily dosing 2
• Refer for endoscopy with prolonged wireless pH monitoring off medication 2
• Consider adjunctive therapy: alginate antacids, nighttime H2 receptor antagonists, or baclofen 2

Critical Pitfalls to Avoid

• Never assume all epigastric pain is GERD-related - exclude cardiac and surgical emergencies first 1, 5
• Do not delay imaging in patients with peritoneal signs - perforated ulcer mortality increases significantly with delayed diagnosis 1, 5
• Atypical cardiac presentations are common in elderly, women, diabetics, and those with chronic renal disease 4, 1
• Persistent vomiting is a red flag requiring investigation for structural disease 5

Lifestyle Modifications

• Advise immediate smoking cessation and alcohol reduction - synergistic dose-dependent effect on gastric ulcer risk 1
• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure 1

Long-Term Management

• Taper PPI to lowest effective dose once adequate symptom control achieved 2
• Consider on-demand therapy or trial of withdrawal with therapy repeated for symptom recurrence 2
• Controlled studies for maintenance therapy do not extend beyond 12 months 3