CT Scan for Epigastric Pain: Indications and Protocols
CT scanning is appropriate for evaluating epigastric pain when there is concern for serious pathology such as gastric cancer, perforated ulcer, or other complications, but is not the first-line imaging test for uncomplicated reflux disease, esophagitis, gastritis, or peptic ulcer disease.
When CT is Appropriate for Epigastric Pain
- CT is valuable when patients present with nonspecific or overlapping symptoms that could indicate serious pathology, especially when there is concern for complications such as perforation, obstruction, or malignancy 1
- CT is particularly beneficial for detecting perforated peptic ulcers, which are surgical emergencies with mortality rates up to 30% 1
- CT can identify gastric cancer, which may present with nonspecific epigastric symptoms and has a 5-year survival rate of only 32% 1
- For patients with suspected gastric outlet obstruction, CT provides excellent anatomic evaluation 1
CT Protocol Recommendations
- For suspected gastric disease, CT should be performed with IV contrast and neutral oral contrast (water or dilute barium suspension) 1
- IV contrast significantly improves detection of:
- Mucosal hyperenhancement due to inflammation
- Focal interruption of mucosal enhancement from ulcer craters
- Nodular or irregular wall thickening that may indicate malignancy 1
- Neutral oral contrast helps delineate the intraluminal space while allowing assessment of mucosal enhancement and potential intraluminal bleeding 1
- CT without IV contrast has limited value and reduced sensitivity for diagnosing gastric pathology 1
CT Findings in Common Epigastric Conditions
Peptic ulcer disease and gastritis:
- Gastric or duodenal wall thickening due to submucosal edema
- Mucosal hyperenhancement or fat stranding from inflammation
- Focal outpouching of mucosa from ulcerations
- Focal interruption of mucosal enhancement 1
Perforated ulcer:
- Extraluminal gas (97% of cases)
- Fluid or fat stranding along gastroduodenal region (89%)
- Focal wall defect and/or ulcer (84%)
- Wall thickening (72%) 1
Gastric cancer:
- Nodular or irregular wall thickening or enhancement
- Soft tissue attenuation of wall thickening
- Perforation with ulcerated mass
- Lymphadenopathy and distant metastases 1
When CT is Not First-Line
- For suspected uncomplicated GERD, esophagitis, gastritis, or peptic ulcer disease without complications, endoscopy is the reference standard 1
- For initial evaluation of reflux symptoms, a biphasic esophagram or upper GI series is more appropriate than CT 1
- For suspected hiatal hernia with respiratory symptoms, chest X-ray is recommended as the first diagnostic study 2
Special Considerations
- Multiphase CT protocols are not routinely needed for epigastric pain evaluation unless acute GI bleeding is suspected 1
- CT is superior to MRI for suspected perforated ulcers due to its ability to detect free air and shorter acquisition time 1
- In pregnant patients with epigastric pain, ultrasonography should be the first diagnostic study, followed by MRI if needed, to avoid radiation exposure 2
Uncommon Causes of Epigastric Pain Detected by CT
- Xiphodynia from an enlarged xiphoid process 3
- Pedunculated exophytic gastric stromal tumors 4
- Perigastric appendagitis (inflammation of fat along perigastric ligaments) 5
Remember that while CT is valuable for diagnosing serious causes of epigastric pain, the appropriate imaging modality should be selected based on the clinical presentation and suspected diagnosis to optimize diagnostic yield while minimizing radiation exposure.