What are the first‑line assessments and management steps for a patient with stomach problems such as pain, nausea, bloating, or heartburn when no red‑flag features are present?

First-Line Assessment and Management of Stomach Problems Without Red Flags

Start with a high-dose proton pump inhibitor (omeprazole 20–40 mg once daily before meals) immediately while conducting a focused diagnostic workup, then adjust therapy based on the predominant symptom pattern and test results. 1

Immediate Clinical Assessment

Identify the most bothersome symptom to guide your diagnostic and therapeutic pathway—asking "which symptom troubles you most?" prevents misclassification and inappropriate treatment. 1

Key History Elements to Elicit

• Timing and meal relationship: Pain appearing 2–5 hours after meals or at night suggests peptic ulcer disease, while immediate postprandial fullness points toward gastroparesis or functional dyspepsia. 1, 2
• Character and location: Burning epigastric pain with heartburn occurring >1 time weekly indicates GERD (affecting 42% of Americans monthly), whereas vague discomfort with bloating suggests functional dyspepsia. 1
• Associated symptoms: Early satiety, nausea, and postprandial fullness characterize gastroparesis or functional dyspepsia; persistent vomiting is a red flag that excludes functional disease. 3, 1
• Medication history: NSAIDs cause gastropathy and ulcers; calcium-channel blockers worsen reflux; opioids impair motility. 1, 4
• Diabetes screening: Ask about polyuria, polydipsia, and neuropathy symptoms—gastroparesis affects 20–40% of patients with long-standing type 1 diabetes. 1

Physical Examination Findings

• Epigastric tenderness on palpation indicates organic pathology rather than functional disease and warrants further investigation regardless of age. 1
• Check for ankle edema and orthopnea to identify heart failure, which can cause nocturnal reflux-type symptoms. 1

Essential Baseline Laboratory Tests

Order these tests at the first visit or ensure they were completed in primary care: 3, 1

• Complete blood count (to detect anemia—an alarm feature)
• C-reactive protein or ESR (to exclude inflammatory conditions)
• Celiac serology (tissue transglutaminase IgA)
• Fasting glucose or HbA1c (to screen for diabetes-related gastroparesis)
• Thyroid function tests (both hyper- and hypothyroidism alter GI motility)

Symptom-Specific Diagnostic Pathways

Predominant Heartburn or Regurgitation

Diagnosis: GERD is diagnosed clinically when heartburn occurs more than once weekly; endoscopy is not required for uncomplicated cases. 1

Management:

• Start omeprazole 20–40 mg once daily 30–60 minutes before breakfast for 4–8 weeks. 1, 4
• Advise remaining upright for 2–3 hours after meals, reducing coffee and citrus intake, and weight loss if obese. 1
• If symptoms persist after 8 weeks, escalate to twice-daily dosing and schedule endoscopy. 1

Predominant Epigastric Pain or Discomfort

Mandatory H. pylori testing: Use ¹³C-urea breath test or stool antigen (serology is not recommended) because eradication eliminates ulcer-related mortality risk. 1, 4

Management algorithm:

• If H. pylori-positive: Treat with triple therapy (omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days), then confirm eradication 4 weeks post-treatment. 1, 4
• If H. pylori-negative or symptoms persist after eradication: Start omeprazole 20–40 mg daily for 4–8 weeks. 1, 4
• If symptoms persist beyond 8 weeks despite PPI therapy: Schedule non-urgent endoscopy within 4–8 weeks. 1

Predominant Nausea with Early Satiety or Bloating

Consider gastroparesis or functional dyspepsia. 5, 2, 6

Initial management:

• Check fasting glucose and HbA1c—hyperglycemia induces gastric hypomotility. 1, 5
• Start omeprazole 20 mg daily plus metoclopramide 10 mg up to four times daily before meals (after discussing side effects). 5
• Add prochlorperazine 5–10 mg orally every 4–6 hours as needed for nausea, or ondansetron 8 mg sublingual every 4–6 hours if metoclopramide causes side effects. 1, 5
• Advise small, frequent meals with reduced fat and fiber; increase caloric intake via liquids. 5

If refractory after 4–6 weeks:

• Consider low-dose amitriptyline 10 mg at bedtime, titrating slowly to 30–50 mg based on response (acts as gut-brain neuromodulator). 4
• Refer to gastroenterology for gastric emptying scintigraphy if severe early satiety persists. 1, 5

Gas Pain and Bloating

Management:

• Trial of low-FODMAP diet if symptoms overlap with IBS features (abdominal pain related to defecation, change in stool frequency or form). 3, 7
• Consider hydrogen breath testing for small intestinal bacterial overgrowth if bloating is severe. 7
• Add antispasmodic (e.g., otilonium bromide) for crampy pain episodes. 1, 7
• Recommend regular aerobic exercise, which improves GI symptoms. 4, 7

When to Perform Endoscopy

Urgent endoscopy (within 2 weeks) is mandatory for: 1

• Age ≥55–60 years with new-onset symptoms
• Unintentional weight loss
• Anemia on CBC
• Dysphagia (food sticking)
• Persistent vomiting
• Hematemesis or melena
• Palpable epigastric mass
• Epigastric tenderness on examination with persistent symptoms

Non-urgent endoscopy (within 4–8 weeks) for: 1

• Treatment-resistant dyspepsia despite 8 weeks of PPI therapy
• H. pylori-positive with ongoing symptoms after eradication
• Persistent epigastric tenderness despite therapy

Critical Pitfalls to Avoid

• Never dismiss cardiac causes: Obtain an ECG in any patient with epigastric pain plus exertional symptoms, dyspnea, or cardiovascular risk factors—myocardial infarction presents as isolated epigastric pain in one-third of cases, especially in women, diabetics, and elderly patients. 1
• Never attribute persistent vomiting to functional dyspepsia—it is a red flag for organic disease such as peptic ulcer, obstruction, or malignancy. 3, 1
• Never prescribe opioids for chronic dyspepsia—they worsen GI motility and cause harm without benefit. 4
• Never delay endoscopy in patients ≥55 years—age alone is an alarm feature that mandates prompt evaluation. 1
• Avoid NSAIDs completely—they worsen peptic ulcer disease and increase bleeding risk. 1, 4

Follow-Up Strategy

• If symptoms resolve within 4–8 weeks: Taper and withdraw PPI, reserving on-demand use for recurrence. 1
• If symptoms persist: Re-evaluate for newly emerging alarm features and escalate to twice-daily PPI dosing before scheduling endoscopy. 1
• Maintain lifestyle modifications (upright posture after meals, reduced coffee/citrus, weight loss) as part of long-term management. 1