What is the best course of treatment for a patient presenting with epigastric pain, sharp pain, vomiting, and nausea for 2 days, with no prior medical history provided?

Management of Acute Epigastric Pain with Vomiting and Nausea

Start high-dose proton pump inhibitor (PPI) therapy immediately—omeprazole 20-40 mg once daily before meals—while simultaneously initiating diagnostic workup, as this achieves 80-90% healing rates for duodenal ulcers and 70-80% for gastric ulcers. 1, 2

Immediate Life-Threatening Exclusions (First 10 Minutes)

• Obtain an ECG within 10 minutes to rule out myocardial infarction, which presents with epigastric pain as the primary manifestation in 10-20% of cases, especially in women, diabetics, and elderly patients 1, 3
• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation or sepsis with high specificity 1, 3
• Perform abdominal examination specifically checking for peritoneal signs: abdominal rigidity, absent bowel sounds, and guarding, which indicate perforated peptic ulcer with 30% mortality if treatment is delayed 1, 3

Urgent Laboratory Workup

• Order serum lipase (≥2x normal) or amylase (≥4x normal) to exclude acute pancreatitis, with 80-90% sensitivity and specificity 1
• Order complete blood count and C-reactive protein to assess for inflammatory processes 1
• Order serum lactate levels to evaluate for tissue hypoperfusion and sepsis 1, 3
• Order liver and renal function tests to identify hepatobiliary or renal causes 1, 3
• Order serum electrolytes and glucose to assess metabolic derangements from vomiting 1

Immediate Symptomatic Treatment

Administer antiemetics for nausea and vomiting control:

• Ondansetron 8 mg sublingual every 4-6 hours as first-line serotonin antagonist 1
• Prochlorperazine 5-10 mg every 6-8 hours as dopamine antagonist alternative 1
• Promethazine 12.5-25 mg orally or rectally every 4-6 hours if other agents fail 1
• Metoclopramide or haloperidol as additional dopamine receptor antagonist options 4, 1

Provide IV fluid resuscitation for dehydration from 2 days of vomiting 5

Imaging Strategy Based on Clinical Findings

If peritoneal signs present:

• Order CT abdomen and pelvis with IV contrast immediately as the gold standard for diagnosing perforated peptic ulcer, with 97% sensitivity for detecting extraluminal gas, 89% for fluid/fat stranding, and 84% for focal wall defects 1, 3

If stable without peritoneal signs:

• Proceed to upper endoscopy as the definitive diagnostic test for peptic ulcer disease, gastritis, and esophagitis once patient is hemodynamically stable 4, 1

Critical Red Flags Requiring Urgent Endoscopy

Do not delay endoscopy if any alarm features present:

• Persistent vomiting beyond 48 hours (excludes functional dyspepsia and mandates structural disease investigation) 1, 3
• Age >55 years (increased gastric cancer risk) 4
• Unintentional weight loss 4
• Dysphagia 4
• Evidence of gastrointestinal bleeding 4

Surgical Consultation Criteria

Obtain immediate surgical consultation if:

• Signs of perforation on examination 1, 3
• Hemodynamic instability despite resuscitation 1, 3
• CT evidence of perforation or free air 1, 3
• Severe uncontrolled pain suggesting complications 4

Definitive Management Algorithm

If peptic ulcer disease confirmed:

• Continue omeprazole 20 mg once daily for 4-8 weeks for gastric ulcers or 4 weeks for duodenal ulcers 2
• Test for Helicobacter pylori and provide eradication therapy if positive: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg twice daily for 10 days 2

If gastroesophageal reflux disease or gastritis:

• Continue omeprazole 20 mg once daily for up to 4 weeks for symptomatic GERD 2
• Extend to 4-8 weeks if erosive esophagitis present 2

If gastroparesis suspected (delayed gastric emptying without obstruction):

• Initiate dietary modifications with liquid diet for severe symptoms 4
• Add prokinetic agents (metoclopramide) for moderate symptoms 4
• Consider cognitive behavioral therapy for refractory cases 4

Critical Pitfalls to Avoid

• Never dismiss cardiac causes regardless of patient age, as myocardial infarction commonly presents with isolated epigastric pain 1, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with diagnostic delays 1, 3
• Persistent vomiting for 2 days is a red flag that excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer disease, gastric outlet obstruction, or acute coronary syndrome 1, 3
• Do not assume all epigastric pain is GERD-related without excluding peptic ulcer disease, pancreatitis, and cardiac causes 4, 1
• Avoid NSAIDs for pain control as they worsen peptic ulcer disease 6

Special Consideration: Boerhaave's Syndrome

If pain onset immediately after excessive vomiting episode:

• Consider esophageal rupture (Boerhaave's syndrome), which requires immediate CT chest and surgical consultation, as mortality is extremely high if untreated 7