I have had intermittent dull epigastric pain for 3 days, now more frequent and unrelated to meals; what evaluation and management do you recommend?

Evaluation and Management of Intermittent Epigastric Pain

You need an urgent upper endoscopy within 2 weeks and should start omeprazole 40 mg once daily before meals immediately while awaiting the procedure. 1

Immediate Assessment

Your 3-day history of increasingly frequent epigastric pain requires urgent evaluation because the progression and persistence of symptoms warrant exclusion of serious organic pathology before considering functional causes.

Critical First Steps

• Obtain an ECG immediately to exclude myocardial ischemia, as acute coronary syndrome can present with epigastric pain and carries a 10-20% mortality rate if missed. 1, 2
• Order complete blood count, comprehensive metabolic panel, serum amylase or lipase, and C-reactive protein to evaluate for pancreatitis, anemia, and other serious conditions. 1
• Test for Helicobacter pylori using a ^13C-urea breath test or stool antigen (not serology), as eradication eliminates peptic ulcer mortality risk. 1, 3

Why You Need Urgent Endoscopy

The American Gastroenterological Association mandates urgent upper endoscopy (within 2 weeks) for patients with persistent epigastric pain lasting beyond 3 days that is worsening in frequency. 1 This is especially critical because:

• Persistent symptoms suggest organic pathology rather than functional dyspepsia. 1
• Delaying endoscopy when symptoms are progressive can lead to missed serious pathology and poorer outcomes. 1
• Endoscopy will assess for erosive esophagitis (Los Angeles classification), Barrett's esophagus, hiatal hernia, peptic ulcer disease, and gastric pathology. 1

Start Treatment Now

Begin omeprazole 40 mg once daily, taken 30-60 minutes before meals, immediately while awaiting your endoscopy. 1, 3

• Full-dose PPI therapy achieves 80-90% healing of duodenal ulcers and 70-80% healing of gastric ulcers within 4 weeks. 1
• This provides symptom relief while diagnostic workup proceeds. 1

What the Endoscopy Will Show

The endoscopy will definitively diagnose:

• Peptic ulcer disease – accounts for approximately 10% of upper GI symptoms; ulcers appear as craters with smooth or irregular margins. 4, 5
• Gastritis – manifests as enlarged areae gastricae, thickened folds, or erosions. 4, 5
• GERD/Esophagitis – presents as fine nodularity, erosions, or thickened folds; note that >50% of GERD patients have normal endoscopy. 4, 5
• Gastric cancer – appears as nodular wall thickening, ulcerated mass, or irregular mucosa (less likely but must be excluded). 4

Additional Imaging If Needed

If endoscopy is normal but symptoms persist, obtain CT abdomen and pelvis with IV contrast to evaluate for:

• Complications like perforation (97% show extraluminal gas on CT). 5
• Gastric outlet obstruction or mass lesions not well-visualized endoscopically. 4
• Other intra-abdominal pathology. 4

Critical Red Flags to Watch For

Seek immediate emergency care if you develop:

• Sudden, severe pain – suggests perforation with 30% mortality if treatment is delayed. 5
• Persistent vomiting – excludes functional dyspepsia and mandates urgent evaluation. 1, 5
• Black, tarry stools or vomiting blood – indicates GI bleeding requiring emergency endoscopy. 5
• Unintentional weight loss – alarm feature requiring urgent investigation. 1, 3
• Fever, tachycardia >110 bpm, or hypotension – suggests perforation or sepsis. 1

What NOT to Do

• Do not take NSAIDs (ibuprofen, naproxen) – they worsen peptic ulcer disease and increase bleeding risk. 1
• Do not delay endoscopy based on whether the PPI helps your symptoms – alarm features override symptomatic response. 3
• Do not assume this is "just indigestion" – persistent, worsening epigastric pain requires structural evaluation. 1

Follow-Up Plan

• Re-evaluate after 4 weeks of PPI therapy; if symptoms persist despite treatment, this further confirms the need for endoscopy. 1
• If H. pylori is positive, complete eradication therapy and confirm clearance with repeat stool antigen or breath test 4 weeks after treatment. 3
• If a gastric ulcer is found, repeat endoscopy in 8-12 weeks to document healing and obtain repeat biopsies to exclude malignancy. 3

Lifestyle Modifications to Start Now

• Remain upright for 2-3 hours after meals – avoid lying down within 45 minutes of eating. 1
• Reduce coffee consumption – caffeine increases gastric acid secretion. 1
• Limit citrus fruits – commonly trigger dyspeptic symptoms. 1
• Elevate head of bed if symptoms worsen at night. 1