In a middle‑aged adult with four months of persistent epigastric pain, no family history of gastrointestinal disease, no prior medical or surgical problems, and a BMI of 31, which initial test is most appropriate: upper endoscopy, Helicobacter pylori testing, or barium esophagram?

Initial Testing for Four Months of Upper Gastric Pain

The most appropriate initial test is H. pylori testing (Option B), not upper endoscopy or barium esophagram. 1, 2

Why H. pylori Testing First

H. pylori testing should be performed as the baseline investigation for this patient because they lack alarm features that would mandate immediate endoscopy. 1 The British Society of Gastroenterology explicitly recommends breath or stool testing for H. pylori as part of baseline investigations for dyspepsia. 1

Key Clinical Context

This patient presents with:

• Four months of epigastric pain (chronic symptoms)
• No family history of gastrointestinal disease
• No alarm features mentioned (no weight loss, dysphagia, bleeding, or persistent vomiting)
• Age appears to be under the threshold requiring immediate endoscopy
• BMI of 31 (elevated but not an automatic endoscopy indication) 2

When Upper Endoscopy Would Be Indicated Instead

Upper endoscopy should be reserved for specific circumstances that do not apply to this patient:

Urgent 2-Week Wait Endoscopy Required For:

• Dyspepsia with weight loss if age ≥55 years 1, 3
• Dyspepsia and age >40 years from an area at increased risk of gastric cancer or with family history of gastroesophageal malignancy 1

Non-Urgent Endoscopy Considered For:

• Treatment-resistant dyspepsia if age ≥55 years 1
• Persistent symptoms despite adequate PPI trial and negative H. pylori testing 2

This patient has none of these indications. 1

Complete Baseline Investigation Panel

Beyond H. pylori testing, the following should be ordered:

• Full blood count if patient is aged ≥55 years (to detect anemia as an alarm feature) 1, 3
• Coeliac serology if there are overlapping IBS-type symptoms 1, 3
• H. pylori breath or stool test (the primary answer to this question) 1

Why Not Barium Esophagram

Barium esophagram (Option C) is not appropriate as an initial test for this presentation. 1 Fluoroscopic studies are indicated when:

• Clinical suspicion exists for hiatal hernia with specific symptoms 1
• Evaluating structural abnormalities after failed empirical therapy 1
• Assessing for scirrhous gastric carcinoma when endoscopy is non-diagnostic 1

A biphasic esophagram provides anatomic and functional information but is not a first-line test for undifferentiated epigastric pain. 1, 3

Critical Management Algorithm After H. pylori Testing

If H. pylori Positive:

• Initiate eradication therapy with 14-day regimen (concomitant therapy or bismuth quadruple therapy in areas of high clarithromycin resistance) 4
• Add high-dose PPI therapy 4
• Confirm eradication 4-6 weeks after completing treatment 4

If H. pylori Negative:

• Start empirical PPI therapy (omeprazole 20-40 mg once daily) 3, 5
• Reassess in 4-8 weeks 1
• If symptoms persist despite adequate PPI trial, then consider endoscopy 2

Common Pitfalls to Avoid

Ordering immediate endoscopy without alarm symptoms exposes patients to unnecessary procedural risks, sedation risks, and costs without improving outcomes. 2 The invasive nature of endoscopy makes it inappropriate as a first-line test when non-invasive testing can guide initial management. 2

Misinterpreting elevated BMI (31 in this case) as an automatic endoscopy indication leads to unnecessary procedures. 2 BMI alone does not constitute an alarm feature requiring endoscopy. 2

Skipping H. pylori testing and proceeding directly to empirical PPI therapy misses the opportunity to eradicate infection, which reduces long-term risk of peptic ulcer disease and gastric cancer. 4, 6, 7 H. pylori infection is present in up to 50% of the world's population and causes 90% of peptic ulcer cases. 6, 7, 8