Diagnosis and Initial Management of Epigastric Pain with Burning and Vomiting
The presence of persistent vomiting with epigastric pain and burning warrants urgent evaluation for serious organic pathology rather than functional dyspepsia, as vomiting suggests another disorder beyond functional disease. 1
Critical Warning Signs Requiring Immediate Action
Persistent vomiting is a red flag that excludes functional dyspepsia and mandates investigation for structural disease. 1 The combination of epigastric pain, burning, and vomiting raises concern for:
- Peptic ulcer disease (PUD) with complications - particularly gastric outlet obstruction, perforation, or bleeding 2, 3, 4
- Acute coronary syndrome - especially in patients with cardiac risk factors, as myocardial infarction can present with epigastric pain 1, 3
- Duodenal injury or obstruction - epigastric pain with vomiting is the classic presentation (100% of cases in trauma series) 5
Immediate Assessment Required
Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension - these predict anastomotic leak, perforation, or sepsis with high specificity. 1 In any patient with epigastric symptoms:
- Obtain stat ECG to exclude myocardial ischemia, particularly in women, diabetics, and elderly patients who may present atypically 1
- Assess for peritoneal signs - sudden severe pain with abdominal rigidity indicates perforation with mortality up to 30% and requires immediate surgical consultation 2, 3
- Check for occult blood in stool or hematemesis/melena - indicates gastrointestinal bleeding, the most common complication of duodenal ulcers 2, 3
Diagnostic Workup
Laboratory Tests
Order immediately: 1
- Complete blood count
- C-reactive protein (CRP has higher sensitivity/specificity than WBC for surgical disease) 1
- Serum lactate levels
- Liver and renal function tests
- Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis 1
Imaging Strategy
Upper endoscopy is the first-line diagnostic investigation for suspected peptic ulcer disease, as it provides both diagnosis and therapeutic capability. 2, 3
CT abdomen with IV contrast should be obtained if perforation is suspected, looking for: 3
- Extraluminal gas (97% sensitive for perforation)
- Fluid or fat stranding along gastroduodenal region (89%)
- Focal wall defect and/or ulcer (84%)
- Wall thickening (72%)
Differential Diagnosis Priority
Most Likely: Peptic Ulcer Disease with Gastric Outlet Obstruction
Gastric outlet obstruction presents with epigastric pain and postprandial vomiting due to mechanical obstruction. 4 While peptic ulcer disease historically was the most common cause, malignancy (gastric cancer, lymphoma) now predominates with H. pylori eradication and PPI use. 4
Must Exclude Immediately:
- Perforated peptic ulcer - sudden severe pain, fever, abdominal rigidity; mortality 30% 2, 3
- Acute coronary syndrome - obtain ECG before attributing symptoms to GI cause 1, 3
- Acute pancreatitis - check amylase/lipase; presents with epigastric pain and vomiting 1
Functional Dyspepsia is a Diagnosis of Exclusion
Functional dyspepsia requires absence of structural disease on endoscopy AND symptom duration ≥6 months with activity in past 3 months. 1 The Rome IV criteria specifically state:
- Persistent vomiting likely suggests another disorder and should not be attributed to epigastric pain syndrome 1
- Vomiting warrants consideration of another disorder in postprandial distress syndrome 1
Therefore, do not diagnose functional dyspepsia in the presence of persistent vomiting - proceed directly to structural evaluation. 1
Initial Treatment Approach
Before Endoscopy Results
Start high-dose proton pump inhibitor therapy immediately while awaiting diagnostic workup: 1, 6
- Omeprazole 20-40 mg once daily before meals 6
- Full-dose PPI therapy is first-line for ulcer-like dyspepsia (epigastric pain/burning) 1
- PPIs are indicated for duodenal ulcer healing (4-8 weeks), gastric ulcer (4-8 weeks), and erosive esophagitis 6
If H. pylori Positive
Triple therapy for 10-14 days: omeprazole + clarithromycin + amoxicillin to eradicate H. pylori and reduce duodenal ulcer recurrence risk. 6 An additional 14-18 days of omeprazole alone may be needed after antibiotics. 6
Gastric Outlet Obstruction Management
Treatment depends on underlying cause: 4
- Benign disease: PPI therapy, H. pylori eradication, endoscopic balloon dilatation
- Malignant disease: Self-expandable stent placement or surgery
- Refractory cases: Surgical intervention
Common Pitfalls to Avoid
Do not attribute persistent vomiting to functional dyspepsia - this violates Rome IV criteria and delays diagnosis of serious pathology 1
Do not delay endoscopy in patients with alarm features: persistent vomiting, weight loss, anemia, dysphagia, or age-dependent risk factors for gastric cancer 1
Do not miss cardiac causes - always obtain ECG in patients with epigastric pain, especially with exertional component or risk factors 1, 3
Do not ignore tachycardia in patients on beta-blockers - may be the only sign of serious complication 1
Do not assume young age excludes serious pathology - duodenal injuries, tuberculosis, and even gastrinomas can present with epigastric pain and vomiting in young patients 7, 5, 8