What is the diagnosis and treatment for a 48-year-old male with epigastric pain, fullness, nausea, and vomiting, exacerbated by coffee and food intake?

From the Guidelines

The most appropriate treatment plan for this 48-year-old male patient with stomach pain, fullness, and nausea is to test for H. pylori infection and initiate symptomatic treatment with omeprazole 20 mg twice daily, while also recommending dietary modifications to avoid triggers like caffeine and spicy foods. The patient's symptoms, such as pain increasing after eating and vomiting when drinking coffee on an empty stomach, suggest a need for a comprehensive approach that includes both medication and lifestyle changes. According to the British Society of Gastroenterology guidelines on the management of functional dyspepsia 1, all patients with symptoms like these should be offered a stool test or breath test to look for a stomach infection called H. pylori. If the test is positive, they should receive a short course of antibiotic treatment for the infection to see if their symptoms improve. Key points to consider in managing this patient include:

• Testing for H. pylori infection to determine if the patient needs antimicrobial therapy
• Starting omeprazole to reduce stomach acid production, which can help alleviate symptoms of dyspepsia
• Recommending dietary changes to avoid foods that may trigger or worsen symptoms, such as caffeine and spicy foods
• Considering the addition of metoclopramide or dicyclomine for symptom management, as needed, for nausea and painful spasms, respectively
• Scheduling a follow-up appointment to review lab results and assess the patient's response to the treatment, adjusting the treatment plan as necessary. The guidelines also suggest that psychological or behavioural therapies may be beneficial for treating symptoms in functional dyspepsia, as they can help reduce the abnormal sensitivity of the nerves in the upper gut 1. However, the primary approach should focus on addressing potential underlying causes, such as H. pylori infection, and managing symptoms with evidence-based medications and lifestyle modifications.

From the FDA Drug Label

INDICATIONS AND USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis. The Prevention of Nausea and Vomiting Associated with Emetogenic Cancer Chemotherapy Metoclopramide Injection, USP is indicated for the prophylaxis of vomiting associated with emetogenic cancer chemotherapy The Prevention of Postoperative Nausea and Vomiting Metoclopramide Injection, USP is indicated for the prophylaxis of postoperative nausea and vomiting in those circumstances where nasogastric suction is undesirable Small Bowel Intubation Metoclopramide Injection, USP may be used to facilitate small bowel intubation in adults and pediatric patients in whom the tube does not pass the pylorus with conventional maneuvers Radiological Examination Metoclopramide Injection, USP may be used to stimulate gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examination of the stomach and/or small intestine.

The FDA drug label does not answer the question.

From the Research

Patient Symptoms and Treatment

• The patient presents with stomach pain, a feeling of fullness, nausea, and vomiting, which are common symptoms of peptic ulcer disease 2.
• The patient's symptoms worsen after eating and improve with vomiting, which is consistent with peptic ulcer disease 2.
• The patient's symptoms also worsen with coffee consumption on an empty stomach, which may be due to the irritant effects of coffee on the stomach lining.

Diagnostic Approach

• The patient will undergo an H. pylori lab test to determine if the infection is present, as H. pylori is a common cause of peptic ulcer disease 3, 4, 2, 5, 6.
• The patient's symptoms and test results will be used to guide treatment, with a focus on eradicating H. pylori if present and managing symptoms with medications and dietary modifications.

Treatment Plan

• The patient will be prescribed omeprazole 20 mg BID, which is a proton pump inhibitor that reduces gastric acid secretion and is effective in treating peptic ulcer disease 3, 4.
• The patient will also be prescribed metoclopramide 10 mg TID PRN and dicyclomine 20 mg TID PRN to manage symptoms of nausea and vomiting.
• If the H. pylori test is positive, the patient will be prescribed clarithromycin 500mg plus amoxicillin 1g (or metronidazole 500mg if penicillin allergic) for 14 days, in addition to continuing omeprazole, to eradicate the infection 4.
• The patient will be advised to avoid caffeine and spicy foods, which may exacerbate symptoms, and to follow up in two weeks to review lab results and assess response to treatment.