What is the appropriate assessment and management plan for a patient with acute severe non‑radiating epigastric pain (10/10) after eating fish and vegetables, no past medical history, no medications, non‑smoker (vapes), occasional alcohol use, and no known allergies?

Assessment and Management Plan for Acute Severe Epigastric Pain

Immediate Assessment – Rule Out Life-Threatening Causes

Obtain an ECG and cardiac troponin levels immediately to exclude myocardial infarction, as acute coronary syndrome can present with isolated epigastric pain and carries 10–20% mortality if missed. 1 This is critical even in young patients without traditional risk factors, as atypical presentations occur. 1

Vital Signs and Physical Examination

• Record vital signs now: tachycardia ≥110 bpm, fever ≥38°C, or hypotension predict serious complications including perforation or sepsis. 1
• Perform focused abdominal exam for peritoneal signs (rigid abdomen, rebound tenderness, absent bowel sounds); their presence suggests perforated peptic ulcer with 30% mortality when treatment is delayed. 1
• Document the presence and severity of epigastric tenderness, as physical examination tenderness indicates organic pathology rather than functional disease and warrants investigation regardless of age. 1, 2

Differential Diagnosis – Prioritized by Severity

High-Priority Diagnoses (Must Exclude First)

• Peptic ulcer disease (PUD): The acute onset of 10/10 epigastric pain after eating, unrelieved by antacids (Gaviscon), is highly consistent with PUD. 1, 2 PUD has perforation risk of 2–10% with mortality up to 30%. 2
• Acute pancreatitis: Serum amylase (≥4× normal) or lipase (≥2× normal) must be checked, with sensitivity and specificity of 80–90%. 1
• Gastroesophageal perforation: Vaping may contribute to esophageal injury; perforation presents with sudden severe pain. 3

Moderate-Priority Diagnoses

• Acute gastritis: Fish consumption can trigger gastritis or allergic/parasitic reactions (Anisakis). 4
• GERD/esophagitis: Though less likely with 10/10 severity, GERD affects 7% of Americans daily. 1
• Functional dyspepsia: Requires 8 weeks of symptoms and normal endoscopy; acute presentation makes this unlikely. 3, 1

Diagnostic Work-Up

Laboratory Tests (Order Immediately)

• Complete blood count to detect anemia (alarm feature requiring urgent endoscopy). 3, 1
• Comprehensive metabolic panel for electrolytes, renal and hepatic function. 1
• Serum amylase and lipase to exclude acute pancreatitis. 1
• C-reactive protein to assess for inflammatory process. 1

Helicobacter pylori Testing

• Perform non-invasive H. pylori testing (¹³C-urea breath test or stool antigen; serology is NOT recommended) because eradication eliminates peptic ulcer mortality risk. 1, 2 This is mandatory for any patient with epigastric pain. 1

Imaging Strategy

If peritoneal signs are present or perforation is suspected, obtain CT abdomen and pelvis with IV contrast immediately. 3, 1 CT demonstrates:

• Extraluminal gas in 97% of perforations 3, 1
• Fluid or fat stranding in 89% 3, 1
• Focal wall defect in 84% 3, 1

If CT is unavailable, obtain chest and abdominal X-ray to detect free intraperitoneal air. 1

Endoscopy Indications

This patient does NOT meet criteria for urgent endoscopy (age <55 years, no weight loss, no dysphagia, no hematemesis, no persistent vomiting). 3, 1 However:

• If symptoms persist beyond 4–8 weeks despite PPI therapy, schedule non-urgent endoscopy. 1
• If alarm features develop (weight loss, anemia, persistent vomiting, dysphagia), upgrade to urgent 2-week-wait endoscopy. 3, 1

Immediate Management

Pharmacologic Therapy

Start high-dose proton pump inhibitor therapy immediately: omeprazole 40 mg once daily before meals while diagnostic work-up proceeds. 1 Full-dose PPI achieves 80–90% healing of duodenal ulcers and 70–80% healing of gastric ulcers. 1

• For nausea: ondansetron 8 mg sublingual every 4–6 hours (obtain baseline ECG first for QTc assessment). 1
• Alternative antiemetics: promethazine 12.5–25 mg orally/rectally every 4–6 hours or prochlorperazine 5–10 mg every 6–8 hours. 1

Dietary and Lifestyle Modifications

• Remain upright for at least 2–3 hours after meals (avoid lying down within 45 minutes) to reduce reflux. 1
• Reduce coffee consumption, as caffeine increases gastric acid secretion. 1
• Limit citrus fruits and other trigger foods. 1
• Avoid NSAIDs, which are associated with dyspepsia and can cause gastropathy. 3

Follow-Up Plan

If H. pylori Positive

• Initiate standard eradication regimen (clarithromycin-based triple therapy or bismuth-based quadruple therapy). 1
• Confirm eradication with repeat stool antigen or breath test 4 weeks after completing therapy. 1

If H. pylori Negative or Symptoms Persist After Eradication

• Continue omeprazole 20–40 mg daily for 4–8 weeks. 1
• If symptoms resolve, consider tapering PPI with on-demand use for recurrence. 1
• If symptoms persist beyond 4–8 weeks, refer for non-urgent endoscopy. 1

Re-Evaluation Triggers

• Development of any alarm features (weight loss, anemia, persistent vomiting, dysphagia) upgrades indication to urgent endoscopy. 3, 1
• Persistent epigastric tenderness despite therapy warrants endoscopy within 4–8 weeks. 1

Common Pitfalls to Avoid

• Missing cardiac causes: Always obtain ECG and troponin in epigastric pain, regardless of age. 1
• Delaying H. pylori testing: This is mandatory and eliminates ulcer mortality risk. 1, 2
• Attributing severe acute pain to functional dyspepsia: Functional dyspepsia requires 8 weeks of symptoms and normal endoscopy; acute 10/10 pain suggests organic pathology. 3, 1
• Using serology for H. pylori: Only breath test or stool antigen are recommended. 1
• Ordering upper GI series for initial diagnosis: This is not recommended; endoscopy is the gold standard when investigation is needed. 3, 1