What is the treatment for epigastric pain in an adult patient with no known medical history?

Treatment of Epigastric Pain in Adults Without Known Medical History

For an adult with epigastric pain and no known medical history, immediately exclude myocardial ischemia with an ECG, then test for Helicobacter pylori and initiate full-dose PPI therapy (omeprazole 20-40 mg once daily before meals) while arranging systematic follow-up. 1, 2

Immediate Risk Stratification and Exclusion of Life-Threatening Causes

First, obtain an ECG immediately to exclude acute coronary syndrome, as myocardial infarction can present atypically with epigastric pain as the primary manifestation and carries a 10-20% mortality rate if missed. 1, 2 This is particularly critical in patients with cardiovascular risk factors such as obesity. 2

• Check vital signs to identify tachycardia, fever, or hypotension, which predict serious complications like perforation or sepsis. 1
• Assess for signs of peritonitis including guarding, rebound tenderness, and board-like rigidity, as sudden severe epigastric pain with fever and abdominal rigidity suggests perforation with 30% mortality if treatment is delayed. 3, 4
• Order complete blood count, comprehensive metabolic panel, serum amylase or lipase, and C-reactive protein to evaluate for pancreatitis and other conditions. 1

Diagnostic Workup for Uncomplicated Epigastric Pain

Test for H. pylori infection in all patients without alarm features, as eradication eliminates peptic ulcer mortality risk even though many patients may have residual functional symptoms. 2, 1 This test-and-treat strategy is cost-effective and safe provided appropriate follow-up is organized. 2

Alarm Features Requiring Urgent Endoscopy:

• Age ≥40 years in high-risk populations or ≥55 years in average-risk populations 2, 1
• Unintentional weight loss 1, 3
• Dysphagia 1
• Persistent vomiting 1
• Family history of gastric or esophageal cancer 2, 1
• Occult blood in stool or signs of bleeding 3

Initial Pharmacologic Treatment

Initiate full-dose PPI therapy with omeprazole 20-40 mg once daily before meals for 4-8 weeks, as healing rates are 80-90% for duodenal ulcers and 70-80% for gastric ulcers with PPI therapy. 2, 5 The FDA approves omeprazole for short-term treatment of active duodenal ulcer (4 weeks, with additional 4 weeks if needed) and active benign gastric ulcer (4-8 weeks). 5

H. pylori Positive Patients:

• Triple therapy is preferred: Omeprazole in combination with clarithromycin and amoxicillin to eradicate H. pylori and reduce duodenal ulcer recurrence risk. 5
• Dual therapy (omeprazole with clarithromycin alone) is more likely to be associated with clarithromycin resistance development and should be reserved for specific situations. 5
• Eradication of H. pylori eliminates the risk of peptic ulcer mortality, as approximately 10% of patients with dyspepsia have peptic ulcer disease. 2

H. pylori Negative or Persistent Symptoms:

• Continue full-dose PPI therapy for ulcer-like dyspepsia with epigastric pain worsened by meals. 2
• If inadequate response after 4 weeks, increase PPI dosing to twice daily or switch to a more potent acid suppressive agent. 1

Management of Refractory Symptoms

Refer for endoscopy if symptoms persist despite 8 weeks of optimized PPI therapy or if alarm features develop. 1, 3 Endoscopy with biopsy is superior to upper GI series because it allows direct visualization, assessment of ulcer characteristics, and targeted biopsies to exclude malignancy. 3

• Perform endoscopy with prolonged wireless pH monitoring off medication to confirm GERD, phenotype the disease, or rule out GERD in patients with persistent symptoms. 1
• All gastric ulcers require biopsy and histological examination to exclude malignancy, as ulceroproliferative features can represent adenocarcinoma. 3
• Consider adjunctive therapy personalized to symptom phenotype, including alginate antacids, nighttime H2 receptor antagonists, and baclofen. 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients presenting with epigastric pain—obtain ECG and troponins first. 3, 1
• Always organize systematic follow-up after initiating test-and-treat strategy to ensure symptom resolution and identify patients requiring escalation to endoscopy. 2
• Do not assume benign disease without tissue diagnosis when evaluating gastric ulcers on endoscopy. 3
• Recognize that up to two-thirds of peptic ulcer cases are asymptomatic, so absence of classic symptoms does not exclude serious pathology. 3
• Be aware that physical examination alone cannot rule out perforation, as up to one-third of patients with perforated peptic ulcer may have minimal or absent peritoneal signs. 3, 4

Long-Term Management

Taper PPI to the lowest effective dose once adequate symptom control is achieved, and consider on-demand therapy or trial of withdrawal with therapy repeated for symptom recurrence. 1 Controlled studies for maintenance healing of erosive esophagitis do not extend beyond 12 months. 5