What is the best approach to quickly manage sharp epigastric pain and nausea in a 14-year-old patient?

Immediate Management of Sharp Epigastric Pain and Nausea in a 14-Year-Old

For rapid symptom relief in a 14-year-old with sharp epigastric pain and nausea, administer ondansetron 4 mg orally immediately for nausea control, followed by omeprazole 20 mg once daily before meals for acid suppression, while simultaneously ruling out life-threatening cardiac and surgical emergencies. 1, 2, 3, 4

Critical First Steps: Rule Out Life-Threatening Causes

Before focusing solely on symptom management, you must exclude emergencies that present with epigastric pain in adolescents:

• Obtain an ECG within 10 minutes to exclude myocardial ischemia, as cardiac causes can present atypically with epigastric pain even in younger patients, carrying 10-20% mortality if missed 1, 2, 5
• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict serious complications like perforation or sepsis with high specificity 1, 5
• Order serum lipase or amylase urgently—levels ≥2x normal for lipase or ≥4x normal for amylase confirm acute pancreatitis with 80-90% sensitivity and specificity 1, 5
• Assess for peritoneal signs (abdominal rigidity, rebound tenderness, absent bowel sounds) that indicate perforated peptic ulcer, which has 30% mortality if treatment is delayed 1, 2

Immediate Symptomatic Management

Nausea Control

Administer ondansetron 4-8 mg orally or sublingually every 4-6 hours as first-line antiemetic therapy for rapid symptom relief 1, 4. The FDA-approved dosing for pediatric patients is weight-based, but 4-8 mg is appropriate for adolescents 4. Obtain a baseline ECG before administration due to QTc prolongation risk 1, 4.

Alternative antiemetics if ondansetron is contraindicated:

• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Prochlorperazine 5-10 mg every 6-8 hours 1

Acid Suppression for Pain Relief

Start omeprazole 20 mg once daily before meals immediately while awaiting diagnostic workup 1, 5, 3. This achieves 80-90% healing rate for duodenal ulcers and 70-80% for gastric ulcers, providing rapid pain relief in acid-related pathology 1, 2, 5.

For pediatric patients 2-16 years:

• Weight 10 to <20 kg: 10 mg once daily 3
• Weight ≥20 kg: 20 mg once daily 3

The medication should be taken before meals and can be opened and mixed with applesauce if the patient cannot swallow capsules whole 3.

Essential Laboratory Workup

Order these tests immediately to guide further management:

• Complete blood count to detect anemia (alarm feature requiring urgent endoscopy) 1, 5
• Comprehensive metabolic panel including serum electrolytes and glucose 1, 5
• Liver function tests to exclude hepatobiliary pathology 1, 5
• C-reactive protein and serum lactate to assess for inflammatory or ischemic processes 1, 5
• Serum amylase or lipase to exclude acute pancreatitis 1, 2, 5

When to Escalate to Imaging

Order CT abdomen with IV contrast immediately if:

• Peritoneal signs are present (rigidity, rebound, absent bowel sounds) 1, 2, 5
• Vital signs are unstable (tachycardia, fever, hypotension) 1, 5
• Pain is sudden and severe, suggesting perforation or vascular emergency 1, 2
• Diagnosis remains unclear after initial assessment 2, 5

CT with IV contrast shows extraluminal gas in 97% of perforations, fluid or fat stranding in 89%, ascites in 89%, and focal wall defects in 84% 1, 2, 5.

Critical Pitfalls to Avoid

• Never attribute persistent vomiting with epigastric pain to functional disease—this combination warrants urgent evaluation for serious organic pathology, as vomiting is a red flag that excludes functional dyspepsia per Rome IV criteria 1, 5
• Do not delay endoscopy if alarm features are present: persistent vomiting, weight loss, anemia, dysphagia, or symptoms lasting >8 weeks with epigastric tenderness 1
• Avoid NSAIDs completely, as they worsen peptic ulcer disease and increase bleeding risk 5
• Do not dismiss cardiac causes based on age alone—atypical presentations occur even in adolescents, particularly with risk factors 2, 5

Pain Management Beyond Acid Suppression

If epigastric pain persists despite PPI therapy and organic causes are excluded:

Consider tricyclic antidepressants for visceral pain modulation: Amitriptyline 10 mg at night, titrated by 10 mg weekly to 25-50 mg at night, is more effective than selective serotonin reuptake inhibitors for epigastric pain 6, 5. Tertiary amines (amitriptyline, imipramine) provide greater benefits than secondary amines (nortriptyline) for pain control, though they have more anticholinergic side effects 6.

Common side effects include sedation, dry mouth, and constipation, which typically improve with continued use 6.

Duration of Initial Treatment

Continue omeprazole for 4-8 weeks for suspected peptic ulcer disease or erosive esophagitis 1, 3. Most patients heal within 4 weeks; some may require an additional 4 weeks 3. If symptoms persist beyond 8 weeks despite therapy, endoscopy is warranted regardless of age 1.