What could be causing my nocturnal epigastric pain and what are the best treatment options?

Nocturnal Epigastric Pain: Diagnosis and Treatment

Immediate Assessment

You need urgent evaluation to rule out serious causes, particularly if you're over 40 years old, have lost weight, or have other alarm symptoms. Nocturnal epigastric pain that wakes you from sleep is concerning and requires systematic evaluation before empiric treatment 1.

Red Flags Requiring Urgent Endoscopy

• Age ≥40 years with new-onset dyspepsia warrants 2-week wait endoscopy, especially if you're from an area with increased gastric cancer risk or have family history of gastro-esophageal malignancy 1
• Unintentional weight loss at any age requires urgent investigation 1
• Persistent vomiting, dysphagia, or evidence of gastrointestinal bleeding mandate immediate endoscopy 1

Initial Diagnostic Workup

Get tested for H. pylori infection first using either stool antigen test or urea breath test—not serology 1. This is critical because:

• H. pylori eradication eliminates peptic ulcer mortality risk, even if symptoms persist 1
• Testing should occur before starting acid suppression therapy for accuracy 1

Obtain basic laboratory studies:

• Complete blood count if age ≥25 years to screen for anemia 1
• Consider coeliac serology if you have overlapping IBS-type symptoms 1

First-Line Treatment

If H. pylori Positive

Eradicate H. pylori with triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all taken twice daily for 10 days 2. If an ulcer is present, continue omeprazole 20 mg once daily for an additional 18 days 2.

For Acid-Related Nocturnal Pain

Start omeprazole 20 mg once daily, taken 30-60 minutes before your first meal 1, 3, 2. This is the most potent acid suppressant available and superior to H2-receptor antagonists 3. Nocturnal epigastric pain that wakes you from sleep is typically acid-related and responds well to PPI therapy 1.

Assess response at 4-8 weeks 1, 3:

• If symptoms resolve, attempt to wean to the lowest effective dose or on-demand therapy 1, 3
• If partial response, increase to omeprazole 40 mg once daily or switch to twice-daily dosing 1, 3
• If no response after 8 weeks of optimized therapy, proceed to endoscopy and consider prolonged wireless pH monitoring off medication 1, 3

Adjunctive Therapy for Breakthrough Nocturnal Symptoms

Add an H2-receptor antagonist at bedtime (famotidine 20-40 mg or ranitidine 150-300 mg) specifically for nocturnal breakthrough pain despite PPI therapy 3, 4. This targets nighttime acid production that PPIs may not fully suppress 3, 4.

Use alginate-antacids (Gaviscon) for post-prandial symptoms that occur after evening meals, as these create a physical barrier superior to antacids alone 3, 4.

Lifestyle Modifications

Elevate the head of your bed by 6-8 inches using blocks under the bed frame—not just pillows—to prevent nocturnal reflux 3, 4. This is particularly important for nighttime symptoms 3.

Avoid eating within 3 hours of bedtime to reduce nocturnal acid exposure 3, 4.

Eliminate specific triggers: caffeine, alcohol, chocolate, fatty foods, and peppermint, especially in evening hours 3, 4.

When to Escalate Care

If symptoms persist after 8-12 weeks of optimized PPI therapy, you need endoscopy to exclude erosive esophagitis (Los Angeles grade B or greater), Barrett's esophagus, or peptic ulcer disease 1, 3. Complete endoscopic evaluation should include:

• Assessment for erosive esophagitis using Los Angeles classification 1
• Evaluation of hiatal hernia and diaphragmatic flap valve (Hill grade) 1
• Inspection and biopsy for Barrett's esophagus if present 1

If endoscopy is normal, perform prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm or rule out GERD and determine your reflux phenotype 1, 3.

Second-Line Treatment for Refractory Symptoms

Consider low-dose tricyclic antidepressants (amitriptyline starting at 10 mg at bedtime, titrating by 10 mg weekly to maximum 30-50 mg) if symptoms persist despite confirmed acid suppression 1, 4. These work as neuromodulators for visceral hypersensitivity, not as antidepressants 1.

Referral for cognitive behavioral therapy or hypnotherapy may be beneficial if there's evidence of esophageal hypervigilance or reflux hypersensitivity 1, 4.

Critical Pitfalls to Avoid

Never use metoclopramide for epigastric pain or GERD—there is insufficient evidence for efficacy and significant risk of tardive dyskinesia 3, 4.

Avoid opioids entirely as they worsen gastrointestinal symptoms and delay gastric emptying 5, 4.

Do not continue long-term PPI therapy without objective confirmation of GERD if you've been on treatment for more than 12 months 1, 3. At the one-year mark, consider reflux testing off medication to determine appropriateness of lifelong therapy 1.

Do not ignore alarm symptoms: If you develop new weight loss, persistent vomiting, difficulty swallowing, or evidence of bleeding, seek immediate evaluation regardless of your response to therapy 1.