What are the differential diagnoses and management plan for a 56-year-old man with epigastric pain described as a 'hungry‑stomach'?

Epigastric Pain with "Hungry Stomach" Character in a 56-Year-Old Man

Immediate Assessment: Rule Out Life-Threatening Causes First

Obtain a 12-lead ECG within 10 minutes of presentation to exclude myocardial infarction, which carries 10–20% mortality when missed and frequently presents atypically with epigastric pain in older adults. 1

• Measure serial cardiac troponins at 0 and 6 hours—never rely on a single troponin measurement, even without chest pain or dyspnea 2, 1
• Check vital signs immediately: tachycardia ≥110 bpm, fever ≥38°C, or hypotension predict perforation or sepsis with high specificity 2, 1
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds); their presence indicates perforation with ~30% mortality if treatment is delayed 2, 3, 1
• Order serum lipase; a level ≥2× upper limit of normal has 80–90% sensitivity and specificity for acute pancreatitis 2, 1

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Most Likely Diagnosis: Peptic Ulcer Disease

The "hungry stomach" pain pattern—epigastric discomfort relieved by food intake or antacids and occurring between meals or at night—is classic for peptic ulcer disease, which affects approximately 10% of patients presenting with upper abdominal pain in primary care. 4, 5

Why PUD is the Leading Diagnosis:

• Duodenal ulcer pain characteristically appears 2–5 hours after meals or during the night when the stomach is empty 3
• Pain relieved by food or antacids strongly suggests acid-related pathology 5
• At age 56, this patient has significant risk for both H. pylori infection (present in ~42% of PUD cases) and NSAID-related ulcers (36% of cases) 4

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Differential Diagnoses to Consider

1. Functional Dyspepsia (Epigastric Pain Syndrome)

• Accounts for ~80% of patients with epigastric symptoms in the community, but is a diagnosis of exclusion requiring normal endoscopy 2
• Rome IV criteria require bothersome epigastric pain ≥1 day per week for >8 weeks with no structural disease 2, 1
• Critical pitfall: Age ≥55 years with new-onset symptoms is an alarm feature that mandates endoscopy before assuming functional disease 2, 3, 1

2. Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly; presents with heartburn, regurgitation, and epigastric pain 2, 3
• However, the "hungry pain" pattern is less typical for GERD, which usually worsens after meals 3
• More than 50% of GERD patients have normal endoscopy (non-erosive reflux disease) 3

3. Gastric Cancer

• Five-year survival is only 32%; now the most common cause of gastric outlet obstruction in adults 2
• Age >55 years is itself an alarm feature requiring 2-week-wait endoscopy to exclude malignancy 2, 3, 1

4. Gastroparesis

• Presents with nausea, vomiting, and postprandial fullness worsening at night 3
• Less likely given the "hungry pain" pattern, but consider if patient has diabetes (present in 20–40% of type 1 diabetics) 3

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Diagnostic Work-Up Algorithm

Step 1: Baseline Laboratory Tests (Order Immediately)

• Complete blood count to identify anemia—an alarm feature mandating urgent endoscopy 2, 1
• Comprehensive metabolic panel including liver function tests 1
• Serum lipase to exclude pancreatitis 2, 1
• Non-invasive H. pylori testing using ¹³C-urea breath test or stool antigen (serology is NOT recommended) 2, 3, 1

Step 2: Determine Need for Urgent Endoscopy

Age ≥55 years with new-onset dyspeptic symptoms is an alarm feature that requires urgent upper-GI endoscopy within 2 weeks to exclude malignancy—do not defer endoscopy solely because other alarm features are absent. 2, 3, 1

Additional Alarm Features Requiring 2-Week-Wait Endoscopy:

• Unintentional weight loss 2, 3
• Anemia on CBC 2, 1
• Dysphagia (food sticking) 2, 3
• Persistent vomiting 2, 3
• Hematemesis or melena 2, 3
• Palpable epigastric mass 3
• Epigastric tenderness on examination (suggests organic pathology) 3, 1

Step 3: Imaging if Diagnosis Unclear or Complications Suspected

• Right upper quadrant ultrasound first-line for suspected biliary colic 1
• CT abdomen/pelvis with IV contrast if perforation suspected: shows extraluminal gas in 97%, fluid/fat stranding in 89%, focal wall defect in 84% 2, 3, 1

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Management Plan

Immediate Empiric Therapy (Start While Awaiting Endoscopy)

Initiate high-dose proton pump inhibitor therapy with omeprazole 20–40 mg once daily before meals immediately while diagnostic work-up is pending. 2, 1

• Full-dose PPI achieves 80–90% healing of duodenal ulcers and 70–80% healing of gastric ulcers within 4 weeks 2, 1, 4
• Ulcers >2 cm may require 8 weeks of treatment 4

If H. pylori Testing is Positive:

• Start standard eradication therapy: clarithromycin-based triple regimen or bismuth-based quadruple regimen (bismuth + metronidazole + tetracycline + omeprazole) 1, 4, 6
• Eradication decreases ulcer recurrence from 50–60% to 0–2% 4, 7
• Confirm eradication with repeat stool antigen or breath test 4 weeks after completing therapy 3

NSAID Management:

• Discontinue all NSAIDs immediately—discontinuation heals 95% of ulcers and reduces recurrence from 40% to 9% 4, 5
• If NSAID continuation is unavoidable, switch to lower-risk agent (e.g., ibuprofen instead of ketorolac), add PPI, and eradicate H. pylori 4

Lifestyle Modifications:

• Avoid food intake within 3 hours of bedtime 1
• Reduce coffee consumption (increases gastric acid secretion) 3
• Limit citrus fruits and high-fat meals 1
• Elevate head of bed 6–8 inches for nocturnal symptoms 3, 1

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Follow-Up Strategy

At 2–4 Weeks:

• Assess symptomatic response to PPI therapy 1
• Review H. pylori test results and initiate eradication if positive 1
• Ensure endoscopy is scheduled within 2 weeks given age >55 years 2, 1

At 4–8 Weeks:

• If symptoms persist despite optimal PPI therapy, proceed with endoscopy (if not already done) 2, 3, 1
• Consider escalating to twice-daily PPI (omeprazole 20–40 mg twice daily) for refractory symptoms 3

After Endoscopy:

• If PUD confirmed: continue PPI for 4–8 weeks depending on ulcer size 4
• If gastric ulcer found: repeat endoscopy in 8–12 weeks to confirm healing and exclude malignancy 4
• If normal endoscopy and symptoms persist: diagnose functional dyspepsia and consider prokinetics or neuromodulators 1

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Critical Pitfalls to Avoid

• Never dismiss cardiac causes in a 56-year-old with epigastric pain—obtain ECG and troponins first 2, 1
• Do not delay endoscopy in patients ≥55 years; age alone is an alarm feature 2, 3, 1
• Never attribute persistent vomiting to functional dyspepsia—it is a red-flag for organic disease 2, 3
• Do not rely on symptom pattern alone to distinguish PUD from functional dyspepsia—endoscopy is required for definitive diagnosis 4, 5
• Avoid single troponin measurement—serial testing at 0 and 6 hours is mandatory 2, 1