What is the initial workup and treatment for a patient presenting with epigastric pain?

Initial Workup and Treatment for Epigastric Pain

The initial workup for epigastric pain should include a thorough clinical assessment to differentiate between common causes such as gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), gastritis, and more serious conditions like myocardial infarction, pancreatitis, or acute aortic syndromes. 1

Differential Diagnosis

Epigastric pain can be caused by various conditions:

• Gastroesophageal reflux disease (GERD) - often accompanied by heartburn and regurgitation 1, 2
• Esophagitis - may present with pain worsened by eating 1
• Peptic ulcer disease (PUD) - duodenal ulcers typically cause pain hours after eating, while gastric ulcer pain occurs immediately after eating 2
• Gastritis - characterized by epigastric pain/burning that may not be related to meals 2
• Duodenal ulcer disease - pain often relieved by food 1
• Gastric cancer - may present with nonspecific symptoms 1
• Hiatal hernia - may cause reflux symptoms 1
• More serious conditions requiring urgent attention:
  • Myocardial infarction - especially with shortness of breath with exertion 1
  • Pancreatitis - pain often radiates to the back 2
  • Acute aortic syndromes - may present with pain radiating to the back 1

Initial Clinical Assessment

• Evaluate specific symptoms accompanying epigastric pain:
  • Heartburn and regurgitation (suggest GERD) 1
  • Dysphagia (suggests esophageal pathology) 1
  • Nausea and vomiting (may indicate gastritis, PUD, or obstruction) 1
  • Hematemesis (suggests bleeding ulcer or malignancy) 1
• Assess timing of pain in relation to meals:
  • Pain relieved by meals suggests duodenal ulcer 2
  • Pain worsened by meals suggests gastric ulcer 2
• Evaluate for alarm symptoms requiring urgent workup:
  • Shortness of breath or chest pain (possible cardiac etiology) 1
  • Pain radiating to the back (possible pancreatic disease or aortic pathology) 1, 2
  • Hematemesis (gastrointestinal bleeding) 1

Diagnostic Workup

Initial Testing

• Laboratory tests:

  • Complete blood count (to assess for anemia or infection) 3
  • Basic metabolic panel (to evaluate renal function) 3
  • Liver function tests (to assess for hepatobiliary disease) 3
  • Lipase and amylase (if pancreatitis is suspected) 3
  • H. pylori testing (if PUD is suspected) 1

• Bedside ultrasonography:

  • First-line imaging for acute epigastric pain in emergency settings 3
  • Can evaluate gallbladder, liver, pancreas, and identify free fluid 3

Further Imaging Based on Clinical Suspicion

• For suspected GERD, esophagitis, gastritis, PUD, or duodenal ulcer:

  • Upper endoscopy is the standard test of choice 1
  • Fluoroscopy with upper GI series is beneficial for evaluating structural and functional abnormalities 1

• For suspected gastric cancer:

  • Upper GI series or CT abdomen and pelvis with IV contrast are usually appropriate 1
  • CT should be performed with IV contrast and neutral oral contrast 1

• For suspected hiatal hernia:

  • Fluoroscopy with biphasic esophagram, single-contrast esophagram, or upper GI series 1

Initial Treatment Approach

For GERD/Acid-Related Disorders

• Proton pump inhibitors (PPIs):
  • Omeprazole 20 mg once daily for symptomatic GERD (up to 4 weeks) 4
  • Omeprazole 20 mg once daily for 4-8 weeks for erosive esophagitis 4

For Peptic Ulcer Disease

• For active duodenal ulcer:

  • Omeprazole 20 mg once daily for 4 weeks 4
  • If H. pylori positive, triple therapy:
    • Omeprazole 20 mg twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 10 days 4

• For active gastric ulcer:

  • Omeprazole 40 mg once daily for 4-8 weeks 4

For Gastric Outlet Obstruction

• Endoscopic lumen enhancement:
  • Wire-guided dilation or balloon dilation 1
  • Endoscopy or fluoroscopy-guided placement of covered expandable metal stents for severe cases 1

Common Pitfalls and Caveats

• Avoid assuming all epigastric pain is due to acid-related disorders; consider serious conditions like myocardial infarction, pancreatitis, or aortic dissection 1, 5
• Older adults may present with atypical symptoms, leading to delayed or missed diagnoses 5
• Symptoms of different conditions often overlap, making clinical history, risk factors, and associated symptoms crucial for narrowing the differential diagnosis 1
• Endoscopy should be prioritized in patients with alarm symptoms (weight loss, dysphagia, recurrent vomiting, GI bleeding, or family history of upper GI cancer) 1
• Avoid relying solely on CT for initial diagnosis of GERD or PUD, as it has limited sensitivity for these conditions 1