What is the most likely diagnosis and appropriate initial management for a male patient with recurrent nocturnal right upper quadrant pain lasting 10–15 minutes, temporarily relieved by food, accompanied by nausea without vomiting, globus sensation, and heightened odor sensitivity, and no fever or vomiting?

Most Likely Diagnosis: Peptic Ulcer Disease (Duodenal Ulcer)

This patient's presentation is classic for peptic ulcer disease, specifically duodenal ulcer, characterized by nocturnal pain awakening from sleep around 2 AM, temporary relief with food intake, and recurrent episodic epigastric/RUQ pain lasting 10–15 minutes. 1, 2

Clinical Reasoning for Peptic Ulcer Disease

The symptom pattern strongly suggests duodenal ulcer rather than other differential diagnoses:

• Nocturnal pain awakening at 2 AM is highly characteristic of duodenal ulcer, occurring when the stomach is empty and acid production peaks 1, 2
• Temporary relief with food intake followed by recurrence after several hours is pathognomonic for duodenal ulcer, as food buffers gastric acid temporarily 1, 2
• Episodic pain lasting 10–15 minutes fits the pattern of peptic ulcer disease, which presents with recurrent episodes rather than constant pain 2
• Epigastric pain with RUQ radiation occurs in approximately 10% of primary care patients presenting with upper abdominal pain who have peptic ulcer as the underlying cause 1

Why This is NOT Biliary Colic or Acute Cholecystitis

The American College of Radiology and World Journal of Emergency Surgery criteria help distinguish this presentation from biliary pathology:

• Biliary colic episodes last ≥30 minutes (typically 1–5 hours), not 10–15 minutes 3, 4
• Biliary pain does NOT improve with food intake; in fact, fatty meals often trigger biliary colic 3, 4
• Absence of fever and Murphy's sign argues strongly against acute cholecystitis 4, 5
• Pain that awakens from sleep can occur with biliary disease but is a supportive criterion, not diagnostic, whereas it is highly specific for duodenal ulcer when combined with food relief 3, 1

Why This is NOT Functional Dyspepsia

The British Society of Gastroenterology guidelines distinguish functional dyspepsia from organic disease:

• Functional dyspepsia requires exclusion of structural disease and typically presents with bothersome symptoms severe enough to impact daily activities occurring ≥3 days per week for PDS or ≥1 day per week for EPS 3
• The classic duodenal ulcer pattern (nocturnal awakening, food relief, predictable timing) suggests organic pathology requiring investigation before labeling as functional 3
• Vomiting is atypical for functional dyspepsia, and this patient has significant nausea, which warrants investigation for structural disease 3

Initial Management Algorithm

Step 1: Test for Helicobacter pylori Immediately

All patients with suspected peptic ulcer disease should undergo non-invasive H. pylori testing as the first diagnostic step. 3, 1

• Order urea breath test or monoclonal fecal antigen test, which have high sensitivity and specificity for active infection 6
• Do NOT use serology, as it cannot distinguish active from past infection 6
• H. pylori is present in approximately 42% of peptic ulcer disease cases 1

Step 2: Initiate Empiric Proton Pump Inhibitor Therapy

Start omeprazole 20 mg twice daily or lansoprazole 30 mg twice daily immediately while awaiting H. pylori results. 1, 2

• PPIs heal 80–100% of peptic ulcers within 4 weeks 1
• Do NOT delay PPI therapy waiting for test results, as acid suppression provides symptomatic relief and prevents complications 1, 2

Step 3: Eradication Therapy if H. pylori Positive

If H. pylori testing is positive, initiate triple therapy: amoxicillin 1 gram twice daily + clarithromycin 500 mg twice daily + lansoprazole 30 mg twice daily for 14 days. 7, 1

• Triple therapy achieves 86–92% eradication rates 7
• H. pylori eradication reduces ulcer recurrence from 50–60% to 0–2% 1
• Confirm eradication with repeat urea breath test or fecal antigen test 4–6 weeks after completing therapy 7, 6

Step 4: Upper Endoscopy Indications

Refer for urgent upper endoscopy if ANY of the following alarm features are present: 3

• Age ≥55 years with new-onset dyspepsia
• Unintentional weight loss (objective documentation required)
• Evidence of gastrointestinal bleeding (hematemesis, melena, anemia)
• Progressive dysphagia
• Persistent vomiting
• Family history of gastric or esophageal cancer

For patients <55 years without alarm features, endoscopy can be deferred if symptoms improve with PPI therapy and H. pylori eradication. 3, 1

However, if symptoms persist despite 4–8 weeks of PPI therapy and H. pylori eradication (if positive), proceed to upper endoscopy regardless of age to confirm diagnosis and rule out complications. 1, 2

Critical Pitfalls to Avoid

Do NOT Order Right Upper Quadrant Ultrasound as Initial Test

• The American College of Radiology recommends RUQ ultrasound for suspected biliary pathology, NOT for this presentation 3, 8
• This patient's symptom pattern (nocturnal pain, food relief, short duration episodes) does not meet criteria for biliary colic 3, 4
• Ordering unnecessary imaging delays appropriate treatment and increases costs 3, 8

Do NOT Obtain Liver Function Tests or GGT Initially

• Elevated GGT would suggest cholestatic pathology, which is inconsistent with this presentation 8
• Focus laboratory workup on H. pylori testing, NOT hepatobiliary enzymes 1, 6

Do NOT Prescribe NSAIDs or Aspirin

• NSAIDs are etiologic factors in 36% of peptic ulcer disease cases 1
• Explicitly counsel patient to avoid all NSAIDs, including over-the-counter ibuprofen and naproxen 1, 2
• If NSAIDs are absolutely necessary for other conditions, continue PPI therapy indefinitely 1

Do NOT Misinterpret Globus Sensation and Odor Sensitivity

• These symptoms likely represent associated functional overlay or anxiety related to recurrent pain, not primary pathology 3
• Do not let these atypical features distract from the classic peptic ulcer presentation 3, 1
• Address these symptoms after treating the underlying peptic ulcer disease 3

Expected Clinical Course

• Symptomatic improvement should occur within 3–7 days of starting PPI therapy 1, 2
• Complete ulcer healing typically requires 4 weeks for duodenal ulcers 1
• If symptoms do not improve within 2 weeks despite PPI therapy, proceed to endoscopy to confirm diagnosis and assess for complications 1, 2
• After successful H. pylori eradication, ulcer recurrence rates drop to 0–2% 1