MKSAP quiz: Management of epigastric pain

This month's quiz asks readers to determine the most appropriate treatment for a 55-year-old woman with throbbing and sometimes burning epigastric pain who has not responded to a four-week trial of omeprazole.

A 55-year-old woman is evaluated for a 6-month history of throbbing and sometimes burning epigastric pain. The pain occurs 2 to 3 times per week and often subsides with eating. She reports no weight loss, nausea, or vomiting, and no bowel symptoms. She tested negative for Helicobacter pylori infection. Her pain did not respond to a 4-week trial of omeprazole. The patient also has anxiety, hypothyroidism, and type 2 diabetes mellitus controlled by diet. Her family medical history is unremarkable. Her medications are lorazepam and levothyroxine.

On physical examination, vital signs are normal. Epigastric tenderness to palpation is noted. Other findings are normal.

A complete blood count, liver chemistry tests, and thyroid-stimulating hormone level are normal. Hemoglobin A1C level is 6.7%.

Upper endoscopy findings are normal. Gastric and small-bowel biopsies are normal.

Which of the following is the most appropriate next step in management?

A. CT scan of the abdomen
B. Gastric emptying test
C. Initiation of a tricyclic antidepressant
D. Twice-daily proton pump inhibitor therapy
E. Ultrasonography of the right upper quadrant

MKSAP Answer and Critique

The correct answer is C. Initiation of a tricyclic antidepressant. This content is available to MKSAP 18 subscribers as Question 86 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.

Starting a trial of a tricyclic antidepressant is the most appropriate next step in the management of this patient. The patient has functional dyspepsia meeting the diagnostic criteria for epigastric pain syndrome: (1) bothersome postprandial fullness; (2) early satiety; (3) epigastric pain; and/or (4) epigastric burning for at least 3 days per week. These criteria should be met for the 3 months leading up to diagnosis, with symptoms starting at least 6 months before diagnosis and with no evidence of structural disease to explain the symptoms. The absence of an underlying organic disease is demonstrated by this patient's normal upper endoscopy, including gastric and small-bowel biopsies, as well as normal laboratory testing and the lack of alarm features such as vomiting, weight loss, or family history of gastrointestinal malignancy. Because she tested negative for Helicobacter pylori infection and her symptoms did not respond to a trial of once-daily omeprazole for a minimum of 4 weeks, the recommended next step in the treatment of functional dyspepsia is a trial of a tricyclic antidepressant. In the treatment of functional dyspepsia, this class of antidepressants was found to be more effective than other classes, including selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors.

Given this patient's absence of alarm symptoms and normal laboratory test results, further structural testing with CT imaging or abdominal ultrasonography is likely to be of low yield; therefore, such testing is neither clinically indicated nor cost effective.

A gastric emptying test is used to evaluate suspected gastroparesis. Gastroparesis commonly presents with symptoms of early satiety, postprandial fullness, nausea, vomiting, upper abdominal pain, bloating, and weight loss; this patient's lack of compatible symptoms makes the diagnosis unlikely.

There is no evidence that a higher dose of a proton pump inhibitor performs better in the treatment of functional dyspepsia than once-daily omeprazole, which did not alleviate the patient's symptoms.

Key Point

  • First-line treatment for functional dyspepsia is once-daily omeprazole for at least 4 weeks; if symptoms do not respond, a tricyclic antidepressant is the next recommended treatment.