What is the approach to diagnosing intermittent epigastric (upper middle abdominal) pain versus chest pain in an 18-year-old patient?

From the Guidelines

For an 18-year-old with intermittent epigastric pain, I would begin with a focused history and physical examination, distinguishing it from chest pain by location (upper middle abdomen versus chest) and associated symptoms, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Initial workup should include basic laboratory tests such as complete blood count, comprehensive metabolic panel, lipase, and amylase to evaluate for common causes like gastritis, peptic ulcer disease, or pancreatitis.

• An H. pylori test would be appropriate given its prevalence in this population.
• For immediate symptom management, I would recommend starting with an acid suppression trial using a proton pump inhibitor such as omeprazole 20mg daily for 2-4 weeks, along with lifestyle modifications including avoiding spicy foods, alcohol, NSAIDs, and large meals before bedtime, as suggested by the ACR Appropriateness Criteria for epigastric pain 1. If symptoms persist or worsen, further evaluation with upper endoscopy would be warranted to directly visualize the esophagus, stomach, and duodenum, as recommended by the ACR Appropriateness Criteria for epigastric pain 1. Unlike chest pain workup, which focuses on ruling out cardiac causes with ECG and cardiac enzymes, epigastric pain evaluation centers on gastrointestinal pathology, as supported by the 2021 ACR Appropriateness Criteria for epigastric pain 1. This approach is justified because in young patients, gastrointestinal causes of epigastric pain are far more common than serious cardiac conditions, though both presentations require thorough evaluation to ensure appropriate diagnosis and treatment. Key considerations in the diagnosis of epigastric pain include:
• Clinical suspicion for acid reflux or esophagitis or gastritis or peptic ulcer or duodenal ulcer
• Use of medications such as nonsteroidal anti-inflammatory agents, potassium supplements, iron, or bisphosphonates
• Presence of symptoms such as heartburn, regurgitation, or dysphagia, and relief with antacid or antisecretory agents
• Findings suggestive of the diagnosis of gastritis or PUD on CT, such as gastric or duodenal wall thickening due to submucosal edema, mucosal hyperenhancement or fat stranding due to inflammation, fluid along the gastroduodenal region, focal outpouching of the mucosa resulting from ulcerations, focal interruption of mucosal enhancement resulting from an ulcer crater eroding through the epithelial lining of the mucosal layer into the submucosal layer or muscularis propria, focal perforation of a gastric ulcer with associated free air, or gastric outlet obstruction due to edema or chronic inflammatory changes near the antrum and pylorus.

From the Research

Diagnosing Intermittent Epigastric Pain versus Chest Pain

• The approach to diagnosing intermittent epigastric pain versus chest pain in an 18-year-old patient involves considering a broad differential diagnosis, including cardiac causes that may be mistaken for gastrointestinal disorders, as well as various serious intra-abdominal causes 2.
• Epigastric pain may occur as a specific and localized symptom, as part of a group of symptoms that include heartburn, or in association with bloating or early satiety, making it essential to guide providers through the appropriate considerations for advanced imaging 3.
• A diagnostic strategy for patients presenting with heartburn and epigastric pain refractory to empiric proton pump inhibitor therapy involves an algorithmic approach, including an initial symptom evaluation, endoscopy, distal esophageal biopsies, esophageal motility, and 24-h ambulatory pH monitoring to assess esophageal function and pathological acid exposure 4.

Considerations for Epigastric Pain

• Peptic ulcer disease is a common cause of epigastric pain, typically related to Helicobacter pylori infection or NSAID use, and can lead to serious consequences if undiagnosed 5.
• Rare causes of abdominal pain, such as well-differentiated neuroendocrine tumors (NETs) or gastrinomas, should also be considered in the differential diagnosis, especially in young patients with persistent symptoms 6.

Diagnostic Evaluation

• Laboratory testing and advanced imaging, such as endoscopy, CT scans, and endoscopic ultrasound (EUS), play a crucial role in evaluating patients with epigastric pain and guiding management decisions 2, 4, 6.
• A scoring system based on the presence of symptoms and severity of findings can be useful in distinguishing between different conditions, such as gastroesophageal reflux disease (GERD), non-erosive reflux disease (NERD), and reflux-like dyspepsia (RLD) 4.