A patient presents with upper abdominal pain in the epigastric area after eating, what could it be and what is the treatment?

Upper Abdominal Pain After Eating: Differential Diagnosis and Treatment

Start with a proton pump inhibitor (PPI) such as omeprazole 20 mg once daily before meals for 4-8 weeks after testing for H. pylori, as functional dyspepsia accounts for 80% of cases and responds to acid suppression with healing rates of 80-90% for duodenal ulcers. 1, 2

Immediate Assessment: Exclude Life-Threatening Causes First

Before considering functional dyspepsia, you must rule out emergencies:

• Obtain an ECG within 10 minutes to exclude myocardial infarction, which presents atypically with epigastric pain in women, diabetics, and elderly patients with mortality rates of 10-20% if missed 3, 4
• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis 3
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) suggesting perforated peptic ulcer, which has 30% mortality if treatment is delayed 3, 4
• Order serum lipase or amylase if pain radiates to the back, as acute pancreatitis is diagnosed by lipase ≥2x normal with 80-90% sensitivity and specificity 3

Determine Need for Urgent Endoscopy

The British Society of Gastroenterology provides clear age-based criteria:

• Request 2-week wait endoscopy if dyspepsia with weight loss and age ≥55 years, or dyspepsia and age >40 years from an area at increased risk of gastric cancer or with family history of gastroesophageal malignancy 1
• Consider urgent CT scan if abdominal pain and weight loss and age ≥60 years 1
• Consider non-urgent endoscopy if treatment-resistant dyspepsia and age ≥55 years 1
• Other alarm features requiring endoscopy include dysphagia, hematemesis, persistent vomiting, or anemia 3, 5

Most Likely Diagnosis: Functional Dyspepsia

Functional dyspepsia is diagnosed in 80% of patients with dyspepsia following endoscopy and is characterized by bothersome epigastric pain or burning, postprandial fullness, or early satiation without structural abnormality. 1

Clinical Criteria for Diagnosis

The Rome IV clinical criteria require:

• One or more cardinal symptoms (epigastric pain, epigastric burning, postprandial fullness, early satiation) reported as bothersome for more than 8 weeks 1
• Pain characteristics: upper abdomen or epigastrium, present in fasting conditions and/or precipitated or exacerbated by meal ingestion 1
• Pain unrelated to defecation, which differentiates functional dyspepsia from irritable bowel syndrome 1

Two Subtypes Guide Treatment Selection

• Epigastric Pain Syndrome (EPS): bothersome epigastric pain or burning at least 1 day per week, often present regardless of meals 1
• Postprandial Distress Syndrome (PDS): bothersome postprandial fullness or early satiation at least 3 days per week, mainly triggered by meals 1

Baseline Investigations Before Treatment

• Full blood count in patients aged ≥55 years 1
• H. pylori testing using breath or stool testing (not serology) before initiating acid suppression therapy 3, 6
• Coeliac serology if overlap of IBS-type symptoms 1

First-Line Treatment Algorithm

Step 1: Test and Treat for H. pylori

If H. pylori positive, prescribe triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days. 3, 2

• Network meta-analysis shows "test and treat" ranks first in reducing symptoms at 12 months (RR 0.89; 95% CI 0.78-1.0) 3
• Eradication rates with triple therapy are 69-83% in intent-to-treat analysis 2

Step 2: Empiric Acid Suppression

For ulcer-like dyspepsia (predominant epigastric pain/burning), start omeprazole 20 mg once daily before meals for 4-8 weeks. 3, 2, 6

• Healing rates are 80-90% for duodenal ulcers and 70-80% for gastric ulcers 3, 2
• At 4 weeks, 82% of patients with duodenal ulcer healed with omeprazole 20 mg versus 63% with ranitidine 150 mg twice daily (p<0.01) 2
• Complete daytime and nighttime pain relief occurs significantly faster with omeprazole than placebo (p≤0.01) 2

Alternative: ranitidine 150 mg twice daily for symptomatic relief, though less effective than PPIs. 7

• Ranitidine provides symptomatic relief within 24 hours for GERD-related heartburn 7
• For active duodenal ulcer, 73% healed at 4 weeks with ranitidine versus 45% with placebo 7

Step 3: If No Response After 2-4 Weeks

• Switch drug class or increase dosing if initial PPI therapy fails 3, 6
• For predominant fullness, bloating, or early satiety (PDS), consider prokinetic agents after PPI trial, though options are limited 1, 8
• Metoclopramide is the only available effective prokinetic agent, but requires short-term treatment and discussion of possible side effects 8

Step 4: If Symptoms Persist or Relapse

• Apply test-and-treat strategy if not already done before consideration of referral for endoscopy 6
• Low-dose tricyclic antidepressant at bedtime may help for treatment of visceral hypersensitivity 8, 6
• Stop treatment after 4-8 weeks if symptoms respond; if symptoms recur, another course of the same treatment is justified 6

Differential Diagnoses to Consider

Gastroesophageal Reflux Disease (GERD)

• Heartburn coexists in approximately one-third of patients with functional dyspepsia 1
• Burning sensation starting in epigastrium but radiating to chest suggests GERD over functional dyspepsia 1, 3
• GERD affects 42% of Americans monthly and 7% daily 5
• Heartburn is associated with epigastric pain in at least two-thirds of patients with upper gastrointestinal symptoms 1

Peptic Ulcer Disease

• Duodenal ulcers cause epigastric pain several hours after eating, often at night, with hunger provoking pain 9
• Gastric ulcer pain occurs immediately after eating, with food increasing pain 9
• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications in 2-10% of cases 5, 4

Biliary Colic

• Consider abdominal ultrasound if epigastric pain <1 year with characteristics of biliary colic 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age—obtain ECG and serial troponins at 0 and 6 hours 3, 4
• Do not attribute persistent vomiting to functional dyspepsia—Rome IV criteria state this suggests another disorder and mandates investigation 1, 3
• Do not delay endoscopy in patients with alarm features (weight loss, anemia, dysphagia, persistent vomiting, age ≥55 years) 1, 3
• Avoid NSAIDs, which worsen peptic ulcer disease and are associated with dyspepsia in multiple population-based studies 1, 3
• Do not use H. pylori serology for test-and-treat strategy—use breath or stool testing only 3

Lifestyle Modifications

• Frequent small meals and low-fat diet may improve symptoms 8
• Cessation of smoking, avoiding excess alcohol intake, and minimizing coffee intake are recommended 8
• Antacids and over-the-counter histamine-2 receptor antagonists may be helpful as "on-demand" therapy for intermittent symptoms 8