What is the appropriate assessment and management plan for a 33‑year‑old man with a two‑year history of episodic epigastric pain precipitated by coffee, ice cream and matcha with milk, mild gastric inflammation on endoscopy, fatty liver on CT, prediabetes, and no other comorbidities?

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Assessment and Plan

Assessment

Functional Dyspepsia (Epigastric Pain Syndrome) with dietary triggers and prediabetes-associated fatty liver disease.

Ang 33-taong-gulang na lalaking ito ay may recurrent epigastric pain na triggered ng coffee, ice cream, at matcha with milk, na consistent sa functional dyspepsia. 1, 2 Ang previous endoscopy ay nagpakita ng mild gastric inflammation lamang at walang peptic ulcer, at ang CT scan ay nagpakita ng fatty liver na related sa prediabetes. 1 Ang current episode ay characterized ng severe pain (8/10) na kumikirot, radiating to hypogastrium, na temporarily relieved ng buscopan at advil, na typical ng functional dyspepsia with visceral hypersensitivity. 3

Key Clinical Features Supporting Functional Dyspepsia:

  • Bothersome epigastric pain occurring at least 1 day per week, lasting >8 weeks total duration (2 years), meeting Rome IV criteria 1, 2
  • Clear dietary triggers (coffee, dairy products, matcha) na known precipitants ng dyspepsia 4
  • Previous endoscopy showing only mild inflammation, ruling out peptic ulcer disease 1
  • Soft, non-tender abdomen on current exam, excluding acute surgical abdomen 2
  • No alarm features: walang weight loss, anemia, dysphagia, o persistent vomiting 1, 5

Differential Diagnoses to Consider:

  • Peptic ulcer disease: Less likely dahil previous endoscopy showed only mild inflammation, pero hindi pa completely excluded ang recurrent ulceration 6
  • Gastroesophageal reflux disease: Possible overlap, lalo na kung may heartburn symptoms 1
  • Biliary colic: Less likely dahil pain is not right upper quadrant-predominant at walang radiation to back 2
  • Cardiac ischemia: Must be excluded dahil epigastric pain can be atypical presentation, especially sa may prediabetes 2, 6

Plan

Immediate Management (Emergency Department/Outpatient Setting)

1. Exclude Life-Threatening Causes

Obtain 12-lead ECG within 10 minutes to definitively rule out atypical myocardial infarction, which carries 10-20% mortality if missed, especially in diabetic patients who present with atypical symptoms. 2, 6

Check vital signs carefully for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which are highly specific for perforation or sepsis requiring urgent surgical consultation. 2

2. Laboratory Evaluation

Order the following tests:

  • Complete blood count to detect anemia, an alarm feature requiring urgent endoscopy 2, 6
  • Comprehensive metabolic panel including liver function tests to assess hepatobiliary disease and monitor prediabetes 2
  • Serum lipase to exclude acute pancreatitis (level ≥2× upper limit of normal has 80-90% sensitivity) 2
  • H. pylori stool antigen or ^13C-urea breath test (NOT serology) as part of test-and-treat strategy; eradication reduces peptic ulcer mortality 5, 2
  • Fasting glucose and HbA1c to reassess prediabetes status 2

3. Imaging Studies

Right upper quadrant ultrasound as first-line imaging to exclude gallstones, biliary colic, or cholecystitis, given the postprandial nature of symptoms. 2

Consider CT abdomen/pelvis with IV contrast if ultrasound is negative and symptoms persist, to detect peptic ulcer complications (extraluminal gas in 97%, fluid/fat stranding in 89% of perforations) or other structural pathology. 5, 2

Pharmacologic Management

Proton Pump Inhibitor Therapy

Start omeprazole 40 mg once daily, taken 30-60 minutes before breakfast, for 4-8 weeks. 5, 2 Full-dose PPI therapy achieves ulcer healing in 80-90% of duodenal ulcers and 70-80% of gastric ulcers within 4 weeks. 5, 2 Ang symptomatic response to PPI confirms acid-related component pero hindi ito nag-exclude ng need for endoscopy kung may alarm features. 5

H. pylori Eradication (if positive)

If H. pylori testing is positive, initiate standard eradication therapy with clarithromycin-based triple regimen or bismuth-based quadruple regimen. 2 Eradication eliminates peptic ulcer mortality risk, although many patients retain functional dyspepsia symptoms requiring continued PPI therapy. 5

Symptomatic Relief

Continue buscopan (hyoscine butylbromide) 10-20 mg three times daily as needed for visceral pain relief during acute episodes. 3

Use NSAIDs (advil/ibuprofen) sparingly dahil chronic NSAID use can worsen gastric inflammation and increase peptic ulcer risk. 1

Lifestyle and Dietary Modifications

Specific Dietary Recommendations

Strictly avoid identified trigger foods: coffee, ice cream, matcha with milk, and other fatty or dairy-rich foods that consistently precipitate symptoms. 1, 4 Fatty foods delay gastric emptying and worsen postprandial distress. 4

Eat smaller, more frequent meals (5-6 small meals daily instead of 3 large meals) to reduce gastric distension and improve accommodation. 3

Avoid eating within 3 hours of bedtime to reduce nocturnal acid exposure and reflux symptoms. 1, 5

Consider low-FODMAP diet trial for 4-6 weeks if symptoms persist, as up to 40% of functional dyspepsia patients have overlapping IBS. 6, 4

Weight Management for Prediabetes and Fatty Liver

Weight loss should be advised for this patient with prediabetes and fatty liver disease; even 5-10% body weight reduction improves insulin sensitivity and reduces hepatic steatosis. 1 Weight loss also reduces GERD symptoms if present. 1

Recommend Mediterranean diet pattern with emphasis on olive oil, whole grains, lean proteins, and vegetables, which has been associated with reduced dyspepsia symptoms. 4

Behavioral Modifications

Elevate head of bed by 6-8 inches if patient experiences nighttime symptoms or regurgitation. 1, 5

Avoid late-night snacking and maintain regular meal times to establish normal gastric motility patterns. 1, 4

Stress management and relaxation techniques should be incorporated, as psychological factors significantly exacerbate functional dyspepsia. 3

Endoscopic Evaluation

Indications for Repeat Endoscopy

Non-urgent upper endoscopy is NOT immediately required dahil patient is <55 years old, walang alarm features (no weight loss, anemia, dysphagia, persistent vomiting), and may recent endoscopy (2 years ago) showing only mild inflammation. 1, 2

However, repeat endoscopy should be considered if:

  • Symptoms persist despite 8 weeks of full-dose PPI therapy 1
  • New alarm features develop (weight loss, anemia, dysphagia, persistent vomiting) 1, 5
  • Significant change in symptom pattern or severity 1
  • H. pylori-positive and symptoms persist after eradication 5

If endoscopy is performed and shows gastric ulcer, repeat endoscopy in 8-12 weeks is mandatory to document healing and obtain repeat biopsies to definitively exclude malignancy. 5

Follow-up and Monitoring

Schedule follow-up in 2-4 weeks to assess:

  • Response to PPI therapy and dietary modifications 1
  • H. pylori test results and need for eradication therapy 5, 2
  • Laboratory results (CBC, metabolic panel, lipase) 2
  • Prediabetes management and weight loss progress 1

If symptoms persist after 8 weeks of optimal medical therapy, consider:

  • Referral to gastroenterology for repeat endoscopy 1
  • Trial of prokinetic agents (metoclopramide, domperidone) for gastroparesis-like symptoms 3
  • Neuromodulators (low-dose tricyclic antidepressants) for visceral hypersensitivity 3
  • Cognitive behavioral therapy or hypnotherapy for refractory functional dyspepsia 3

Patient Education and Counseling

Reassure the patient that functional dyspepsia is a chronic but benign condition without increased cancer risk, and that symptoms can be effectively managed with lifestyle modifications and medications. 1, 3

Explain the gut-brain connection: stress, anxiety, and psychological factors significantly influence symptom severity and should be addressed as part of comprehensive management. 3

Emphasize the importance of dietary trigger avoidance: coffee, high-fat dairy products, and other identified triggers should be strictly eliminated to prevent recurrent episodes. 4

Discuss prediabetes management: lifestyle modifications including weight loss, regular exercise, and dietary changes are critical to prevent progression to diabetes and improve fatty liver disease. 1

Red Flags Requiring Urgent Re-evaluation

Instruct patient to return immediately if:

  • Severe, persistent pain not relieved by medications 2
  • Fever, chills, or signs of infection 2
  • Vomiting blood or coffee-ground material 1, 5
  • Black, tarry stools or bright red blood per rectum 1, 5
  • Unintentional weight loss >5% body weight 1, 5
  • New-onset dysphagia or odynophagia 1, 5
  • Chest pain, shortness of breath, or diaphoresis 2, 6

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Initial Evaluation of Acute Epigastric Pain in Adults

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

Management of Epigastric Pain with Alarm Features

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Guideline

Differential Diagnosis for Epigastric Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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