What is the diagnosis and treatment for a non-smoking, non-drinking patient with no previous history of gastroesophageal reflux disease (GERD), who experiences epigastric pain after eating, unrelieved by Tums (calcium carbonate), and has a preference for spicy foods and soda?

Diagnosis and Treatment for Epigastric Pain After Eating

Most Likely Diagnosis

This patient most likely has peptic ulcer disease (PUD), specifically a duodenal ulcer, given the epigastric pain after eating that is unrelieved by antacids, combined with dietary triggers (spicy foods and soda). 1, 2, 3

Differential Diagnosis to Consider

The epigastric pain after eating a fatty meal (burger) with failure to respond to antacids suggests:

• Peptic ulcer disease (duodenal or gastric ulcer) - Most likely given symptom pattern 1, 3
• Gastritis - Common with dietary triggers like spicy foods and carbonated beverages 4, 5
• Functional dyspepsia - Possible but less likely given acute presentation after specific meal 4
• GERD/esophagitis - Less likely as primary diagnosis since no heartburn history, though 66% of GERD patients have epigastric pain 5, 6

Critical: Rule out myocardial infarction first - Obtain ECG and cardiac troponins immediately, as MI can present with isolated epigastric pain with 10-20% mortality if missed. 5

Immediate Diagnostic Workup

Essential First Steps

• Obtain ECG within 10 minutes and serial cardiac troponins at 0 and 6 hours to exclude acute coronary syndrome, especially since epigastric pain can be the sole manifestation of MI. 5
• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension suggesting complications like perforation or bleeding. 5
• Perform focused physical exam looking for peritoneal signs (guarding, rebound tenderness, rigidity) that would indicate perforation requiring immediate imaging. 1
• Order complete blood count to assess for anemia from occult bleeding. 5
• Test stool for occult blood as bleeding is the most common PUD complication. 1, 3

When to Order Advanced Imaging

CT abdomen/pelvis with IV contrast is indicated if:

• Peritoneal signs are present (perforation has 30% mortality if delayed) 1, 5
• Fever, tachycardia, or hemodynamic instability 5
• Severe, sudden-onset pain suggesting perforation 1

CT is NOT needed initially if the patient is hemodynamically stable with no peritoneal signs and cardiac causes are excluded. 4

Treatment Algorithm

Immediate Management (First 24-48 Hours)

Start high-dose PPI therapy immediately - Omeprazole 40 mg once daily before breakfast, which achieves 70-80% healing rates for gastric ulcers and 80-90% for duodenal ulcers. 5, 7

• Take PPI 30-60 minutes before meals (preferably breakfast) for optimal acid suppression. 6
• Avoid NSAIDs completely as they worsen PUD and increase bleeding risk. 4, 5
• Maintain NPO status initially if surgical emergency not yet excluded. 5

Lifestyle Modifications (Critical for Healing)

• Eliminate carbonated beverages (soda) and spicy foods that trigger symptoms. 4
• Avoid late meals and remain upright 2-3 hours after eating to reduce acid exposure. 5
• Counsel on alcohol reduction or cessation as alcohol has synergistic effects with other risk factors. 5

Follow-Up Testing (Within 1-2 Weeks)

Test for H. pylori infection using stool antigen test or urea breath test. 6

• If H. pylori positive: Start triple therapy with omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days, then continue omeprazole 20 mg daily for additional 18 days. 7
• If H. pylori negative: Continue omeprazole 40 mg daily for 4-8 weeks. 7

When to Refer for Urgent Endoscopy

This patient does NOT meet criteria for urgent endoscopy unless alarm features develop, as they are under 55 years old without weight loss, dysphagia, bleeding, or progressive symptoms. 4, 1

Refer for endoscopy if:

• Symptoms persist after 4-8 weeks of PPI therapy (treatment-resistant dyspepsia) 4, 1
• Development of alarm symptoms: weight loss, dysphagia, hematemesis, or progressive symptoms 4, 1
• Age ≥55 years with any of the above 4

Expected Response to Treatment

• Most duodenal ulcers heal within 4 weeks; some require additional 4 weeks. 7
• Gastric ulcers require 4-8 weeks for healing. 7
• If no improvement after 4 weeks, reassess for H. pylori status and consider endoscopy. 1, 6

Critical Pitfalls to Avoid

• Never dismiss cardiac causes - Always obtain ECG and troponins first, as MI mortality is 10-20% if missed. 5
• Do not assume benign disease without excluding complications - Sudden severe pain with fever/rigidity suggests perforation with 30% mortality. 1, 5
• Do not rely on antacid response to rule out serious pathology - PUD often fails to respond to antacids but responds to PPIs. 1, 3
• Do not continue NSAIDs - They are strongly associated with dyspepsia and ulcer formation. 4