What is the most likely diagnosis for abdominal pain that improves after eating?

Duodenal Ulcer Disease

Abdominal pain that improves with eating is most characteristic of duodenal ulcer disease, which requires testing for Helicobacter pylori and assessment of NSAID use, followed by appropriate acid suppression therapy. 1

Clinical Presentation

Duodenal ulcer disease classically presents with:

• Epigastric pain relieved by food intake or antacids — this is the hallmark feature that distinguishes duodenal ulcers from other causes of dyspepsia 2
• Pain that awakens patients at night or occurs between meals (when the stomach is empty and acid exposure is maximal) 2
• Pain typically located in the epigastrium, described as gnawing or burning 3, 4

The pathophysiology explains the symptom pattern: food and antacids temporarily buffer gastric acid, providing relief, but as the stomach empties and acid production continues, pain recurs 5. This contrasts with gastric ulcers, where eating may worsen symptoms, and functional dyspepsia, where the pain-meal relationship is inconsistent 1.

Differential Considerations

While duodenal ulcer is the primary diagnosis to consider, important alternatives include:

• Functional dyspepsia — characterized by postprandial fullness and early satiation, but pain relief with eating is not typical 6
• Gastric ulcer or gastritis — typically causes epigastric discomfort but does not follow the characteristic pattern of pain relief with meals 1
• GERD — presents with heartburn radiating to the chest, not deep abdominal pain relieved by eating 1

Diagnostic Approach

Initial Evaluation

For patients under 60 years without alarm features:

• Implement a test-and-treat strategy for H. pylori using non-invasive testing (urea breath test or stool antigen test) 1, 3, 4
• Assess for NSAID use, as this accounts for approximately 36% of peptic ulcer disease cases 4
• Alarm features requiring urgent endoscopy include: weight loss, anemia, dysphagia, persistent vomiting, or age >55 years with new-onset symptoms 6, 1

For patients ≥60 years or with alarm features:

• Endoscopy is the gold standard for definitive diagnosis and should be performed promptly 3, 4, 2
• The British Society of Gastroenterology recommends 2-week wait endoscopy for dyspepsia with weight loss if age ≥55 years 6

Key Diagnostic Pitfall

Do not assume stable symptoms for 3 months exclude serious pathology — while gastric carcinoma is unlikely with stable symptoms and no weight loss, duodenal ulcers can present with chronic, stable symptoms 1. The pain-relief-with-eating pattern is highly suggestive and warrants investigation.

Treatment Algorithm

If H. pylori Positive (42% of cases):

• Eradication therapy reduces ulcer recurrence from 50-60% to 0-2% 4
• Standard regimen: PPI (omeprazole 20 mg twice daily) plus two antibiotics for 10-14 days 1, 3
• Alternative: Vonoprazan-based triple therapy (recently approved, appears superior to conventional PPI-based therapy) 3
• Confirm eradication with repeat testing at least 4 weeks after completing treatment 3

If NSAID-Associated:

• Discontinue NSAIDs — this heals 95% of ulcers and reduces recurrence from 40% to 9% 4
• If NSAID continuation is necessary: add PPI therapy (omeprazole or lansoprazole) and eradicate H. pylori if present 4
• Consider switching to a less ulcerogenic NSAID (e.g., from ketorolac to ibuprofen) 4

Acid Suppression Therapy:

• PPIs are first-line (omeprazole 20 mg once daily before meals) for 4-8 weeks 1, 3
• PPIs heal 80-100% of duodenal ulcers within 4 weeks 4
• H2-receptor antagonists are an alternative but less potent 5, 7
• Omeprazole (a proton pump inhibitor) provides more thorough acid inhibition than H2-blockers and may be preferable for large or complicated ulcers 5

Complications and Red Flags

Peptic ulcer disease complications include:

• Bleeding (73% of complications) — most common indication for surgery, though most bleeds are controlled with PPIs and endoscopic therapy 4, 2
• Perforation (9% of complications) — surgical emergency requiring immediate intervention 4, 2
• Gastric outlet obstruction (3% of complications) — rare but serious 4

Annual mortality from peptic ulcer disease in the US is approximately 10,000 deaths, with bleeding ulcers accounting for 54,000 hospital admissions annually 4.

Prognosis and Follow-Up

• Without treatment, ulcer recurrence rates are 50-60% 4
• With appropriate H. pylori eradication and NSAID cessation, recurrence drops to 0-9% 4
• Patients with persistent symptoms after initial treatment should undergo endoscopy 1, 2
• Maintenance PPI therapy may be considered for patients with frequent symptomatic recurrences or prior complications 7