In a 30-year-old obese man with a four-month history of epigastric pain that worsens after meals and no family history of gastric or esophageal cancer, what is the next step in management?

Management of Dyspepsia in a 30-Year-Old Obese Man

The next step is H. pylori testing using a validated non-invasive method (urea breath test or stool antigen test), followed by eradication therapy if positive or empiric PPI trial if negative. 1

Rationale for This Approach

This 30-year-old patient does not meet criteria for urgent endoscopy because:

• He is under age 55 years (the threshold for age-related alarm features) 1, 2
• He has no alarm symptoms: no weight loss, anemia, dysphagia, persistent vomiting, hematemesis, or palpable mass 1, 2
• He has no family history of gastric or esophageal cancer in a first-degree relative 1
• Four months of symptoms, while chronic, does not constitute an alarm feature in the absence of other red flags 1

The British Society of Gastroenterology 2022 guidelines explicitly recommend that baseline investigations for dyspepsia in patients under 55 years without alarm features should include H. pylori breath or stool testing, not endoscopy. 1

Why Each Option Is Appropriate or Not

A. H. pylori Testing (CORRECT ANSWER)

This is the evidence-based first step for this patient. 1

• Test-and-treat strategy is standard of care for patients under 55 years with dyspepsia and no alarm features 1, 3
• Use urea breath test or validated monoclonal stool antigen test—serology is not recommended for initial diagnosis 1, 4, 5
• If positive: initiate eradication therapy (clarithromycin-based triple therapy or bismuth quadruple therapy for 10-14 days) 1, 4, 5
• If negative: start empiric PPI therapy (omeprazole 20-40 mg once daily before meals for 4-8 weeks) 1, 2, 6
• H. pylori eradication eliminates peptic-ulcer-related mortality risk and prevents future ulcer complications 4, 6
• Meta-analysis shows that 20-50% of H. pylori-positive dyspeptic patients have underlying ulcer disease or duodenitis, making this test highly informative 3

B. Endoscopy (INCORRECT at this stage)

Endoscopy is not indicated as the initial step in this patient. 1

• The British Society of Gastroenterology reserves endoscopy for patients ≥55 years with new-onset dyspepsia or those with alarm features at any age 1, 2
• The yield of endoscopy in young patients without alarm features is extremely low: meta-analysis shows less than 0.5% have gastro-oesophageal malignancy, and approximately 80% have normal endoscopy (functional dyspepsia) 1
• Cost per cancer diagnosis via endoscopy in primary care exceeds US$80,000, making routine endoscopy in low-risk patients prohibitively expensive 1
• Endoscopy should be reserved for treatment-resistant dyspepsia (symptoms persisting beyond 4-8 weeks of PPI therapy) or if alarm features develop 1, 2

C. Abdominal CT (INCORRECT)

CT abdomen is not part of the standard dyspepsia workup in uncomplicated cases. 2

• CT is indicated only when complications are suspected: perforation (sudden severe pain with peritoneal signs), bleeding (hematemesis, melena), or obstruction 2, 6
• This patient has chronic, stable symptoms without acute deterioration, fever, rigidity, or hemodynamic instability 2, 6
• CT findings such as extraluminal gas (97% sensitivity for perforation) or focal wall defects are relevant only in acute surgical emergencies 2

D. Barium Study (INCORRECT)

Barium studies are not recommended for routine diagnosis of dyspepsia or GERD. 2

• Fluoroscopic upper GI series is less sensitive than endoscopy for detecting ulcers, gastritis, and malignancy 2
• The British Society of Gastroenterology states that barium studies should be used only for anatomical delineation (stricture, hiatal hernia) when endoscopy cannot be performed, not as a first-line diagnostic tool 2

Additional Management Considerations

Lifestyle Modifications (Start Immediately)

• Weight loss is critical in this obese patient (BMI 35), as obesity markedly worsens gastroesophageal reflux by increasing intra-abdominal pressure 2, 6
• Remain upright for 2-3 hours after meals; avoid lying down within 45 minutes of eating 2, 6
• Reduce coffee and citrus intake, both of which increase gastric acid secretion and trigger dyspeptic symptoms 2, 6
• Regular aerobic exercise is strongly recommended for all dyspeptic patients 4

If H. pylori Is Positive

• Administer 14-day eradication therapy (clarithromycin-based triple therapy or bismuth quadruple therapy) 1, 4, 5
• Perform test of cure at least 4 weeks after completing antibiotics using breath test or stool antigen (never serology) 4, 5
• Discontinue PPIs for 2 weeks and antibiotics/bismuth for 4 weeks before test of cure to avoid false-negative results 4, 5

If H. pylori Is Negative or Symptoms Persist After Eradication

• Start full-dose PPI therapy (omeprazole 20-40 mg once daily before meals) for 4-8 weeks 1, 2, 6
• If symptoms resolve, consider on-demand PPI use rather than continuous therapy 4, 6
• If symptoms persist beyond 8 weeks of PPI therapy, refer for non-urgent endoscopy 1, 2

Common Pitfalls to Avoid

• Do not order endoscopy in young patients without alarm features—this wastes resources and has extremely low diagnostic yield 1
• Do not use serology for H. pylori diagnosis—IgG antibodies persist for 6-12 months after eradication and cannot distinguish active infection from past exposure 4, 5
• Do not delay H. pylori testing—eradication eliminates peptic-ulcer mortality risk and prevents future complications 4, 6, 3
• Do not assume functional dyspepsia without first excluding H. pylori—20-50% of H. pylori-positive patients have underlying ulcer disease 3
• Do not ignore the patient's obesity—weight loss is a critical intervention that directly improves reflux symptoms 2, 6