What is the appropriate work‑up and management for a patient with persistent epigastric pain lasting one month?

Epigastric Pain for One Month: Diagnostic Work-Up and Management

For a patient with persistent epigastric pain lasting one month, immediately exclude cardiac ischemia with an ECG, then pursue H. pylori testing and initiate empiric high-dose PPI therapy (omeprazole 20-40 mg once daily before meals) while arranging urgent endoscopy if the patient is ≥55 years or has any alarm features (weight loss, anemia, dysphagia, persistent vomiting, epigastric tenderness). 1, 2, 3

Step 1: Exclude Life-Threatening Causes First

Cardiac Assessment

• Obtain an ECG immediately to rule out myocardial infarction, which can present as isolated epigastric pain in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 2, 3
• Check serial troponins at 0 and 6 hours if any cardiovascular risk factors, exertional symptoms, or dyspnea are present 3, 4
• Acute aortic syndromes (dissection or leaking AAA) must be excluded in patients >50 years with vascular risk factors, as these cause sudden severe epigastric pain 2, 3

Imaging for Complications

• If alarm features are present (see below), order CT abdomen/pelvis with IV contrast to detect perforation (97% sensitivity for extraluminal gas), pancreatitis, malignancy, or vascular emergencies 1, 2, 3
• Perforated peptic ulcer carries 30% mortality if treatment is delayed and presents with sudden severe pain, fever, and abdominal rigidity 2, 3

Step 2: Identify Alarm Features Requiring Urgent Endoscopy (Within 2 Weeks)

Any of the following mandates urgent upper endoscopy: 1, 2, 4

• Age ≥55 years with new-onset dyspepsia or epigastric pain 1, 2
• Unintentional weight loss (requires objective documentation) 2
• Anemia on complete blood count 2, 3
• Dysphagia or food sticking at a specific level 2, 4
• Persistent vomiting (red flag that excludes functional dyspepsia) 1, 2
• Hematemesis or melena 2
• Epigastric tenderness on examination (suggests organic pathology rather than functional disease) 2
• Palpable epigastric mass 2

Step 3: Initial Laboratory Work-Up

Order the following tests immediately: 2, 3

• Complete blood count to detect anemia (alarm feature) 2, 3
• Serum electrolytes and glucose 2
• Liver function tests 2
• Serum amylase or lipase (≥4x normal for amylase or ≥2x normal for lipase suggests pancreatitis with 80-90% sensitivity) 2, 3
• C-reactive protein and serum lactate if infection or perforation suspected 2
• Renal function tests 2

Step 4: H. Pylori Testing Strategy

For Patients <55 Years Without Alarm Features

• Perform non-invasive H. pylori testing using ^13^C-urea breath test or stool antigen assay (serology is NOT recommended) 2
• H. pylori is the principal cause of peptic ulcers not related to NSAID use 2
• If H. pylori-positive, initiate standard eradication regimen (clarithromycin-based triple therapy or bismuth-based quadruple therapy) 2
• Confirm eradication with repeat stool antigen or breath test 4 weeks after completing therapy 2

Step 5: Empiric PPI Therapy

Start immediately while awaiting diagnostic results: 2, 3, 4

• Omeprazole 20-40 mg once daily taken before meals for 4-8 weeks 2, 3, 4
• Achieves 80-90% healing of duodenal ulcers and 70-80% healing of gastric ulcers 2, 3, 4
• If symptoms persist after 4-8 weeks of once-daily dosing, escalate to twice-daily PPI and schedule endoscopy 2

Step 6: Endoscopy Timing Based on Risk Stratification

Urgent Endoscopy (Within 2 Weeks)

• Age ≥55 years OR any alarm feature present 1, 2, 4

Non-Urgent Endoscopy (Within 4-8 Weeks)

• Treatment-resistant dyspepsia despite omeprazole 20-40 mg daily for 4-8 weeks in patients ≥25 years 2
• Persistent epigastric tenderness despite therapy 2
• H. pylori-positive with ongoing symptoms after successful eradication 2

Endoscopy NOT Required

• Age <55 years without alarm features AND symptoms improve with PPI therapy within 4-8 weeks 2

Step 7: Adjunctive Symptomatic Management

For Nausea

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 2
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 2
• Prochlorperazine 5-10 mg every 6-8 hours 2

For Crampy Pain

• Otilonium bromide (Spasmomen) blocks calcium channels and reduces bowel spasm 2

Step 8: Lifestyle Modifications

Implement immediately alongside pharmacotherapy: 2

• Remain upright for 2-3 hours after meals (avoid lying down within 45 minutes) 2
• Reduce coffee consumption (caffeine increases gastric acid secretion) 2
• Limit citrus fruits (common trigger for dyspeptic symptoms) 2
• Weight loss in patients with severe obesity (markedly improves reflux) 2
• Avoid NSAIDs including over-the-counter ibuprofen (worsen peptic ulcer disease and increase bleeding risk) 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age—obtain ECG within 10 minutes 3, 4
• Do not delay endoscopy in patients aged ≥55 years; age alone is an alarm feature 2
• Never attribute persistent vomiting to functional dyspepsia—it is a red flag for organic disease 1, 2
• Avoid ordering upper GI series to diagnose GERD or dyspepsia—it is unsupported and may produce false-positives 2
• Do not delay imaging in patients with peritoneal signs—perforated ulcer mortality increases significantly with delayed diagnosis 3

Special Considerations for Specific Populations

Pregnancy

• Consider preeclampsia (epigastric pain with headaches, visual changes, swelling) 2
• Consider HELLP syndrome (epigastric pain, nausea, vomiting, malaise requiring immediate delivery) 2, 3
• Consider acute fatty liver of pregnancy (malaise, jaundice, epigastric pain) 2

Diabetes

• Screen for gastroparesis (present in 20-40% of long-standing type 1 diabetes) with gastric emptying scintigraphy if endoscopy is normal 2
• Check HbA1c as hyperglycemia induces gastric hypomotility 2

Nocturnal Symptoms

• Evaluate for obstructive sleep apnea (negative intrathoracic pressure promotes reflux) 2
• Assess for congestive heart failure (nocturnal fluid redistribution worsens reflux) 2
• Check thyroid function tests (both hyper- and hypothyroidism alter GI motility) 2

Follow-Up Strategy

• If symptoms resolve within 4-8 weeks, consider tapering and withdrawing PPI with on-demand use for recurrence 2
• If symptoms persist beyond 4-8 weeks despite therapy, refer for non-urgent endoscopy to exclude peptic ulcer disease, gastritis, or malignancy 2
• Re-evaluate for any newly emerging alarm features at each visit—their presence upgrades the indication to urgent endoscopy 2